心肌梗死病理、病理生理和临床表现.pptVIP

* 继发性病理变化在心腔内压力的作用下 ,坏死心壁向外膨出，可产生心脏破裂（心室游离壁破裂、心室间隔穿孔或乳头肌断裂）或逐渐形成心室壁瘤。 * * * Strategies for reducing time to treatment Public education to shorten the delay in summoning help Implementation of emergency department thrombolysis protocols Use of rapid diagnostic techniques to confirm AMI Implementation of pre-hospital thrombolysis by trained emergency personnel * * * TIME-TO-TREATMENT AND MORTALITY REDUCTION ARE RELATED The amount of tissue salvageable in myocardial infarction is inversely related to the duration of coronary artery occlusion up to about 5 hours, when myocardial ischaemia becomes irreversible. Very substantial myocardial salvage, and therefore saving of life, is possible if reperfusion therapy is started within 2 hours of the onset of symptoms, and especially within the first “golden” hour. During the first 2–3 hours after symptom onset, time to treatment is a critical determinant of the extent of salvage and reduction in mortality. Subsequently, a benefit persists but the ‘flattening of the curve’ emphasises that time to treatment is less of a factor and the major priority is opening of the infarct-related artery. * * * The figure shows the increase in mortality over time in relation to the start of reperfusion therapy with pharmacological vs. mechanical means, compiling data from a meta-analysis of thrombolysis trials and the NRMI-2 results for mechanical reperfusion. * Different reperfusion strategies are depicted in this figure. The first medical contact is the place (ambulance or hospital) where, at least in principle, reperfusion therapy could be given. The (increasing) time limits for the different reperfusion strategies are also depicted schematically. The thick arrow indicates the preferred strategy. * * 依诺肝素的显著优势在早期（48小时）就显示出来。依诺肝素在心肌梗死、再梗死、死亡率方面的相对风险较普通肝素下降了23.8%。 * ESSENCE研究：依诺肝素与普通肝素相比，显著降低30天终点事件（死亡、MI和复发心绞痛），且14天时就已显现其优势。 * * 美国胸科医师学会指南: “一种低分子肝素的特点不能随意推广到另一种低分子肝素上。正由于此，针对某一特定的低分子肝素的临床研究的结果不能推广到其它的低分子肝素。 强调：依诺肝素经循证医学证据证实的有效