溶栓和急诊pci在急性心梗治疗中作用.pptVIP

Reteplase N=8260 Reteplase +Reopro N=8326 OR (95% CI) P value 30-day mortality 5.9% 5.6% 0.95 (0.84-1.08) 0.43 Re-MI up to 7 days 3.5 2.3 0.66 (0.72-0.93) 0.0001 Stroke (any) 0.9% 1.0% 1.1 (0.8-1.51) 0.55 Intra-cranial bleed 75yrs 1.1 2.1 1.91(0.95-3.84) 0.069 Sever/Mod. Bleed 2.3 4.6 2.03(1.7-2.42) 0.0001 Thrombolysis or PCI in AMI GUSTO V: Primary and Secondary Endpoints 16,588 pts within 6hrs of STEMI randomized to standard dose of reteplase (n=8260) or ?-dose reteplase and full-dose Reopro (n=8328). The GUSTOV Investigators. Lancet 2001;357:1905-14 * Not every patient is eligible for thrombolytic treatment Cerebral/vascular bleed Percent AMI pts with TIMI 3 flow following thrombolysis is less than ideal Thrombolysis or PCI in AMI Limitations of Thrombolysis in AMI Patients * The 90 Minute Wall: 60% Rates of TIMI Grade 3 Flow % TIMI 3 Flow * Incidence and Patho-anatomy of AMI Fibrinolysis for AMI Fibrinolysis Vs. Primary PCI Adjunct Pharmacology and Strategies Current Recommendations in Treatment of AMI Thrombolysis or PCI in AMI * Grines, C. L. et al. N Engl J Med 1993;328:673-679 Thrombolysis or PCI in AMI PAMI: In-Hospital Reinfarction and Death 395 Pts were enrolled in 12 sites with AMI within 12 hrs of symptom onset and randomized to immediate PTCA (n=195) vs. tPA (n=200) By 6 months, reMI or death had occurred in 15.8% of pts treated with tPA and 8.5% treated with PTCA (p=0.02). * Thrombolysis or PCI in AMI Short(4-6wks)-term clinical Outcomes Post 1° PTCA Vs. Thrombolysis Keeley et al, Lancet 2003;361:13-20 Summary of 23 trials totaling 7,739 pts (PTCA=3,872 and Thrombolysis =3,867 pts) 27% 65% 54% 47% * Thrombolysis or PCI in AMI Advantages and Disadvantages of 1° PTCA Vs. Thrombolysis Advantages Disadvantages Superior vessel patency and TIMI 3 flow Lack of generalized availability Early definition of coronary anatomy allows risk stratification Delay in mobilizing cath lab Reduced rates of recurrent ischemia, re-MI, death, and stroke Skilled int