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1 争分夺秒优化流程 STEMI 患者再灌注策略选择首都医科大学附属北京朝阳医院心脏中心王乐丰

2 无论何种再灌注方式, 都应强调 : 时间就是心肌, 时间就是生命 Time Dependent Wavefront of Necrosis

4 时间对再灌注抢救的意义 0 1 hrs 预防心肌梗死, 使梗死流产 1 3 hrs 大量挽救心肌, 获益 PCI= 溶栓 3 6 hrs 心肌挽救降低, 溶栓效果开始不如急诊 PCI 6 12 hrs 基本不挽救心肌, 但可防止梗死扩大 >12hrs 如有症状也可 PCI 干预, 可以改善左室重构

5 一患者基线资料分析第一部分 ECG 法纳入 2015 年 3 月至 2015 年 12 月共计 124 人,A 组 : 3 小时 (n=37);b 组 :>3-6 小时 (n=50);c 组 :>6 小时 (n=37) 三组临床基本资料冠脉造影结果药物治疗无统计学差异 5

6 第一部分 ECG 法三三组心肌梗死面积比较 S2B 时间延长, 心肌梗死面积增加, 差异有统计学意义, STEMI 患者 MIS 与 S2B 具有相关性 ( r=0.48,p<0.001) 6

7 第一部分 ECG 法四不同梗死部位心肌梗死面积比较前壁较非前壁 STEMI 患者心肌梗死面积大 7

9 梗死范围和预后

10 Trials Years enrolled Included Trials N Test Days to test FU duration EMERALD SPECT 10 [7, 13] 183 [179, 188] AMIHOT-II SPECT 16 [14, 18] 366 [353, 374] IMMEDIATE SPECT 33.5 [32, 35] 365 [365, 365] APEX-AMI MRI 4 [3, 5] 365 [184, 367] LIPSIA-ABCIX MRI 2 [2, 3] 188 [184, 194] LIPSIA-N-ACC MRI 3 [2, 4] 190 [185, 245.5] LIPSIA-STEMI MRI 3 [2, 4] 192 [172, 257] CRISP AMI MRI 14 [10, 21] 183 [181, 189] AIDA STEMI MRI 3 [2, 4] 380 [368, 400] INFUSE-AMI MRI 6 [4, 30] 365 [351, 377] Total 2,376 SPECT: 744 (31.3%) MRI: 1,632 (68.7%) 5 [3, 14] 340 [185, 370.5]

11 Median (IQR) Infarct Size (%LV mass) Test type N Days to test Infarct size All 2, [3.0, 14.0] 18.0 [8.0, 30.0] - SPECT [8.5, 17.0] 14.0 [3.0, 30.0] - MRI 1, [2.0, 6.0] 19.1 [10.2, 29.9]

12 1-year Event Rates (N=2,376)

13 Relationship Between Infarct Size and Outcomes (from time of randomization) P= [19.3, 38.0] [8.0, 29.9] [14.0, 35.2] Event [8.0, 30.0] No event P=0.05 P< P< [20.2, 39.5] [8.0, 28.1] [17.0, 38.0] [7.3, 29.0]

17 时间如何争分夺秒

18 2014 年 ESC 的推荐对于 12 小时以内的 STEMI 患者或新发左束支传导阻滞的患者均应再灌注治疗 (Ⅰ/A) STEMI 引起心源性休克或急性左心衰发作, 无论发病时间长短, 均应急诊 PCI 治疗 (Ⅰ/B) 即使发病大于 12 小时, 疼痛消失或心电图 ST 段回落, 如果存在持续性缺血的证据或出现恶性心律失常时仍应急诊 PCI 治疗 (Ⅰ/C) 发病 12~48 小时内的患者应考虑急诊 PCI 再灌注治疗 (Ⅱa/B)

19 2014 年 ESC 的推荐所有溶栓患者均应在 24 小时内转到能行 PCI 的中心 (Ⅰ/A) 溶栓成功后 24 小时行冠脉造影, 以便行血运重建 (Ⅰ/A) 溶栓失败后应紧急补救性 PCI(Ⅰ/A) 溶栓成功稳定患者的最佳造影时机为 3~24 小时 (Ⅱa/A)

20 D 2 B 时间和一年死亡率的关系 2 小时就诊 : D to B 时间 <1.5h 1.9% D to B 时间 1.5h 3.9% 2 小时就诊 : D tob 时间 <1.5h 5.1% D tob 时间 1.5h 4.8% Brodie JACC 2003

25 延迟治疗就是否定治疗症状识别呼叫急救系统院前处理急诊科心导管室心肌细胞丢失增加再灌注治疗时间延迟

26 Introduction primary PCI STEMI Treatment Impacting outcomes Nauta, S. et al, available at urnal.pone

27 Mortality From a Heart Attack How Did We Get Here? Dauerman et al. Am J Cardiol 2002: The Worcester Heart Attack Study

31 Prognostic Significance of Periprocedural vs. Spontaneously Occurring MI After PCI 7773 pts with ACS underwent PCI in ACUITY; peri-procedural MI (CK-MB >3x nl) developed in 466 pts (6.0%), and a spontaneous MI unrelated to PCI (troponin >nl) subsequently developed in 200 pts (2.6%) Cumulative Mortality (%) Periprocedural MI Post PCI MI Spontaneous MI P< % 6.0% 2.6% Days from Randomization Prasad A et al. Submitted Multivariate model of 1-yr mortality Spontaneous MI HR = 7.49 [4.95, 11.33], p< Periprocedural MI HR = 1.30 [0.85, 1.98], p=0.22

33 PCI-related Delay Pinto et al Circulation 2006

34 远程无线诊断启动急诊 PCI 缩短 D-B 时间

35 Table 1. Outcomes According to Transport Method Direct (n = 454) Interhospital (n = 127) P Value First-Medical-Contact-to- Balloon Time < 90 Minutes 82% 23% < 0.01 Median Symptom-to-Balloon Time, min < 0.01 TIMI Flow Grade 3 92% 84% 0.03 One-Year Mortality 7% 13% 0.03

37 2014 年与北京市平均数字的比较朝阳医院数字 n/n(%) 北京市平均数字 n/n(%) 急诊 PCI 6/430(1.4%) 118/5891(2.0%) 择期 PCI 6/1523(0.39%) 32/42418(0.08%) 总 PCI 12/1953(0.61%) 150/48309(0.31%) 我院急诊 PCI 死亡者均为心源性休克或心脏破裂者 ; 择期 PCI 死亡者多为泵功能严重衰竭合并多脏衰者, 反映我科 PCI 患者大多危重, 临床情况较复杂, 期待新型介入诊治器材的引入与应用, 改善结果比较

38 死亡例数 :12 例 (0.61%) 急诊 PCI:6 (1.4%) 择期 PCI:6 (0.39%) 心脏破裂 :1 脑出血 :1 亚急性支架内血栓 :1 泵衰竭多脏衰 :9

39 2014 年死亡病例汇总

40 基线资料 Endeavor 组 vs. Cypher 组发病至入院时间 :215±140 vs. 235±167 分钟, P=0.13 入院至签字时间 :53±61 vs. 59±73 分钟, P=0.28 签字至穿刺时间 :39±21 vs. 43±33 分钟, P=0.05 穿刺至球囊时间 :21±10 vs. 24±24 分钟, P=0.04 Door 2 Balloon 时间 : 113±64 vs. 127±91 分钟, P=0.04

41 北京朝阳医院单中心急诊 PCI 结果分析对上表数据需要说明 : 参与绿色通道的医护人员基本能保证在 30 分钟内全部到位时间耽误环节在患者家中 : 胸痛不及时求助医生, 平均花费时间在 3 小时左右在急诊科 : 患者及家属商量及做出决定耗费很多时间, 平均在 60 分钟左右

42 2017 年 1 月 -9 月

43 心源性休克

52 Intra-aortic Balloon Counterpulsation and Infarct Size in Patients with Acute Anterior MI Without Shock CRISP AMI: 337 pts randomized to primary PCI with or without intraaortic balloon pump (IABP) pre-intervention. IABP Plus PCI (n = 161) Conclusion: IABP therapy fails to reduce infarct size or improve clinical outcomes when added prior to primary PCI in patients with high-risk STEMI but no cardiogenic shock. Patel MR, et al. JAMA. 2011;Epub ahead of print. PCI Alone (n = 176) P Value Mean Infarct Size a 42.1% 37.5% 0.06 Mean LVEF 46.1% 48.2% Month Mortality 1.9% 5.2% 0.12 a Primary endpoint.

53 Intraaortic Balloon Counterpulsation Reduces Mortality in Large Anterior MI Complicated by Persistent Ischemia CRISP-AMI substudy: 36 patients with large STEMI and poor ST-segment resolution (n = 15 IABP and 21 control), representing 11% of overall trial. At 6 months, none of the patients in the IABP group had died, compared with 5 in the control group (0 vs 24%; P =.046) Trend favoring IABP therapy also seen for the composite endpoint of death, cardiogenic shock, or new/worsening heart failure (7% vs 33%; log-rank P =.06). Implications: IABP therapy seems most beneficial in patients with large anterior STEMI complicated by persistent ischemia. van Nunen LX, et al. EuroIntervention. 2014;Epub ahead of print.

54 2014 年 ESC 的推荐 AMI 引起的心源性休克, 如果冠状动脉病变适合 PCI, 则建议急诊 PCI 治疗 (Ⅰ/B) AMI 引起的心源性休克, 如果冠状动脉病变不适合 PCI, 则建议急诊 CABG 治疗 (Ⅰ/B) ACS 患者出现心源性休克可考虑短期机械辅助循环 ( Ⅱ b/c) 不建议常规对心源性休克患者使用 IABP( Ⅲ /A)

55 The Evolution of MI Care >80% Mortality Reduction: Robust Drug/Device Development, Clinical Investigation (evidence-based medicine), and a Dynamic Regulatory Process Courtesy of Aaron Kaplan, MD

56 POST: Ischemic Postconditioning During Primary Percutaneous Coronary Intervention 700 STEMI patients undergoing primary PCI within 12 hours of symptom onset were randomized to direct postconditioning or conventional care. Complete ST-Segment Resolution at 30 min Postconditioning (n = 350) Conclusion: Ischemic postconditioning during primary PCI improves neither myocardial perfusion nor clinical outcomes in STEMI patients. Hahn J-Y, et al. Circulation. 2013;Epub ahead of print. Conventional PCI (n = 350) P Value 40.5% 41.5% 0.79 MACE at 30 Days 4.3% 3.7% 0.70

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