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S.ChiuWongMD,FACCAssociateProfessorofMedicineWeillMedicalCollegeofCornellUniversityDirector,CardiacCatheterizationLaboratoriesTheNewYorkPres

byterianHospital-CornellCampusTheACCSymposiumattheGreatWallMeeting,BeijingChinaOctober17,2004Thrombolysis

orPrimaryPCIintheTreatmentofAcuteMI2021/01/211•Patho-anatomyofAMI•FibrinolysisforAMI•FibrinolysisVs.PrimaryPCI•AdjunctPharmacologyandStrategies

•CurrentRecommendationsinTreatmentofAMIThrombolysisorPCIinAMISummary2021/01/212•Patho-anatomyofAMI•Fi

brinolysisforAMI•FibrinolysisVs.PrimaryPCI•AdjunctPharmacologyandStrategies•CurrentRecommendationsinTreatmen

tofAMIThrombolysisorPCIinAMI2021/01/213Circulation,VolumeXLV,January1972.Page215-230CoronaryArteriesinFatal

AcuteMyocardialInfarctionByWILLIAMC.ROBERTS,M.D.SUMMARYThecoronaryarteriesarediffuselyinvolvedbyatheroscleroticplaquesinfatalacutemyocardialinfar

ction(AMI).Thedegreeofluminalnarrowingmayvarybutplaquesarepresentinpracticallyeverymillimeterofextramuralcorona

ryartery.Usuallythelumensofatleasttwoofthethreemajorcoronaryarteriesarenarrowed>75%byoldplaquesinpatie

ntswhodiesuddenly(<6hours)fromcardiacdiseasewithorwithoutmyocardialnecrosis.Coronarythrombioccurinabout1

0%ofpatientswhodiesuddenlyorinwhomnecrosisislimitedtotheleftventricularsubendocardium,andinabout50%ofpatientswithtransmuralmyocar

dialnecrosis.Coronarythrombiusuallyindicatethepresenceofshockorcongestiveheartfailureorbothduringdiedevelo

pmentofmyocardialnecrosis.Theinfrequencyofcoronarythrombiinpatientsdyingsuddenlyofcardiacdiseaseandinthosewithtransmuralnecros

iswhoneverhaveshockorcongestiveheartfailuresuggeststhatthethrombimaybeconsequencesratherthancausesofAMI.ThrombolysisorPCIinAMIPath

o-AnatomyofAMI2021/01/214ThrombolysisorPCIinAMIPatho-AnatomyofAMI2021/01/215ThrombolysisorPCIinAMIPatho-AnatomyofAMI2021/01/216Thrombolysi

sorPCIinAMIPathophysiologyofST-ElevationMIResultsfromstabilizationofaplateletaggregateatsiteofplaqueruptu

rebyfibrinmeshplateletRBCfibrinmeshGPIIb-IIIaMIgenerallycausedbyacompletelyocclusivethrombusinacoronaryartery2021/01/217•Incidencea

ndPatho-anatomyofAMI•FibrinolysisforAMI•FibrinolysisVs.PrimaryPCI•AdjunctPharmacologyandStrategies•CurrentRecomme

ndationsinTreatmentofAMIThrombolysisorPCIinAMI2021/01/218ThrombolysisorPCIinAMIISIS-2(Secondinternatio

nalstudyofinfarctsurvival)Randomizedtrialcomparing1MUofivstreptokinaseover1hr,oralaspirin,both,ornei

theramong17,187ptswithsuspectedAMIupto24hrsafteronsetofsymptom.Significantreductionofmortalityat35dayswasd

emonstratedforaspirinorstreptokinase,andanadditivebeneficialeffectwiththe2combinedagentswasnoted.ISIS-2CollaborativeGroup.Lancet1988

;332:349–3602021/01/219ThrombolysisorPCIinAMIThrombolyticAgentsforAMIComprehensiveoverviewofthrombolytict

herapyonAMIonearly(5-week)mortalityfromrandomizedtrialsofmorethan1000ptsbythefibrinolyticcollaborativegro

up……FCGThelancet1994;343:311-22ThrombolyticsarebeneficialacrossabroadspectrumofAMIptswithSTEorBBBperhapswiththeexceptioninptswhower

e>75yrsandtreated>12hrsfromsxonsetwere.Theearliertreatmentinitiation,thegreaterthebenefitandthusre-affirmtheconceptof“timeismuscle.”2021/01/2110

•Noteverypatientiseligibleforthrombolytictreatment•Cerebral/vascularbleed•PercentAMIptswithTIMI3flowfollowingthrombolysisislessthanidealThrombolys

isorPCIinAMILimitationsofThrombolysisinAMIPatients2021/01/2111ThrombolysisorPCIinAMIContraindicationsforfibrinolyticsinAMIContraindi

cations•Previoushemorrhagicstrokeatanytime;otherstrokesorcerebrovasculareventswithin1yr•Knownintracranialneoplasm•Activeinternalbleedin

g(doesnotincludemenses)•SuspectedaorticdissectionAdaptedfromRyanTJ,etal.ACC/AHAguidelinesforthemanagementofpat

ientswithAMI.JAmCollCardiol1996;28:1328–14282021/01/2112Relativecontraindications•Severeuncontrolledhypertensiononpresentation(blood

pressure>180/110mmHg)orchronichistoryofseverehypertension•Historyofpriorcerebrovascularaccidentorknownintracerebralpathologynotcoveredincontraind

ications•Currentuseofanticoagulantsintherapeuticdoses(internationalnormalizedratio2–3);knownbleedingdiathesis•Recenttrauma(within2–4wk),includinghea

dtraumaortraumaticorprolonged(>10min)cardiopulmonaryresuscitationormajorsurgery•Noncompressiblevascularpuncture

s•Recent(within2–4wk)internalbleeding•Forstreptokinase/anistreplase:priorexposure(especiallywithin5d–2yr)orprioralle

rgicreaction•PregnancyandActivepepticulcerAdaptedfromRyanTJ,etal.ACC/AHAguidelinesforthemanagementofpat

ientswithAMI.JAmCollCardiol1996;28:1328–1428ThrombolysisorPCIinAMIContraindicationsforfibrinolyticsinAMI2021/

01/2113•Previouslarge-scalerandomizedthrombolyticstudieswouldsuggestthatonly15-20%ofAcuteMI(AMI)patientsarecons

ideredeligibleforreperfusiontherapybyconventionalcriteria•Morerecentobservationalstudies*withbroaderinclusioncriteriawouldestimatethatapproxima

tely45to50%ofAMIptswereeligible(ie.<12hrssymptomonset,chestpainwith≥2mmST↑inany2contiguousECGleadsornewLBB

B)and32-45%ofptsactuallyreceivedthrombolyticagents.ThrombolysisorPCIinAMIEligibilityforThrombolysisinAMIPatientsKarlsonBWe

talCirc1990;82:1140-6,*FrenchJKetalBMJ1996;312:1637-41*ReikvmetalIntJCardiol1997;61:79-832021/01/2114•Noteverypatientiseligibleforthromb

olytictreatment•Cerebral/vascularbleedandre-infarction•PercentAMIptswithTIMI3flowfollowingthrombolysisislessthanidealThrombolysisor

PCIinAMILimitationsofThrombolysisinAMIPatients2021/01/2115ReteplaseN=8260Reteplase+ReoproN=8326OR(95%CI)Pvalue30-daymortality5.9%5.6%0.95(0.

84-1.08)0.43Re-MIupto7days3.52.30.66(0.72-0.93)<0.0001Stroke(any)0.9%1.0%1.1(0.8-1.51)0.55Intra-cranialbleed>75yrs1.12.11.91(0.95

-3.84)0.069Sever/Mod.Bleed2.34.62.03(1.7-2.42)<0.0001ThrombolysisorPCIinAMIGUSTOV:PrimaryandSecondaryE

ndpoints16,588ptswithin6hrsofSTEMIrandomizedtostandarddoseofreteplase(n=8260)or½-dosereteplaseandfull-doseReopro(n=8328).TheGU

STOVInvestigators.Lancet2001;357:1905-142021/01/2116•Noteverypatientiseligibleforthrombolytictreatment•Cerebr

al/vascularbleed•PercentAMIptswithTIMI3flowfollowingthrombolysisislessthanidealThrombolysisorPCIinAMILimitationsofThrombolys

isinAMIPatients2021/01/211760605763020406080100tPArPANPATNK40The90MinuteWall:60%RatesofTIMIGrade3Flow%TIMI3Flow20

21/01/2118•IncidenceandPatho-anatomyofAMI•FibrinolysisforAMI•FibrinolysisVs.PrimaryPCI•AdjunctPharmacologyandStrategies•CurrentRecommendationsinTreat

mentofAMIThrombolysisorPCIinAMI2021/01/2119Grines,C.L.etal.NEnglJMed1993;328:673-679ThrombolysisorPCIinAMIPAMI:I

n-HospitalReinfarctionandDeath395Ptswereenrolledin12siteswithAMIwithin12hrsofsymptomonsetandrandomizedtoimmediatePTCA(n=195)vs.tPA(n=200

)By6months,reMIordeathhadoccurredin15.8%ofptstreatedwithtPAand8.5%treatedwithPTCA(p=0.02).2021/01/212079371281402468101214PercentDeathR

E-MIStrokeCompositePTCAThrombolysisThrombolysisorPCIinAMIShort(4-6wks)-termclinicalOutcomesPost1°PTCAVs.ThrombolysisKeeleyeta

l,Lancet2003;361:13-20Summaryof23trialstotaling7,739pts(PTCA=3,872andThrombolysis=3,867pts)27%65%54%47%2021/01/2121ThrombolysisorPCIinAMIA

dvantagesandDisadvantagesof1°PTCAVs.ThrombolysisAdvantagesDisadvantagesSuperiorvesselpatencyandTIMI3flowLackofg

eneralizedavailabilityEarlydefinitionofcoronaryanatomyallowsriskstratificationDelayinmobilizingcathlabRedu

cedratesofrecurrentischemia,re-MI,death,andstrokeSkilledinterventionalcardiologysrequiredImprovedsurvivalinhighrisk

patientsNolargesinglemortalitytrialdataavailableReducedintracranialbleedShorterlengthofhospitalstayA

llowsreperfusionwhenthrombolyticsarecontra-indicated2021/01/2122•IncidenceandPatho-anatomyofAMI•FibrinolysisforAMI•F

ibrinolysisVs.PrimaryPCI•AdjunctPharmacologyandStrategies•CurrentRecommendationsinTreatmentofAMIThrombolysisorPCIinAMI2021/01/2123Thrombolys

isorPCIinAMITheADMIRALTrial•Multi-center300ptsrandomized,double-blindplacebocontrolledstudytodemonstratet

hesuperiorityofabciximaboverplaceboinprimaryPTCAwithstentinginacutemyocardialinfarctionMontalescotGetalNEJM2001;344:1895-190320

21/01/2124ThrombolysisorPCIinAMIADMIRAL:FrequencyofTIMIIIIFLOW16.85.495.186.795.592.694.382.80102030405060708090100PercentBefore

After24hrs6mthsReopron=149Placebon=151P=0.01P=0.04P=0.33P=0.04MontalescotGetalNEJM2001;344:1895-19032021/01/2125ThrombolysisorPC

IinAMIADMIRAL:CompositeEndpoint@6month3.47.32426.67.415.90246810121416DeathRe-MIUrgentTVRCompositeReopron

=149Placebon=151P=0.13MontalescotGetalNEJM2001;344:1895-1903P=0.32P=0.049P=0.02Reoproimprovescoronarypatencybeforestenting,andclinicaloutcomeat3

0daysand6monthsN=149N=1512021/01/2126ThrombolysisorPCIinAMICAPTIM:StudyDesignPrimaryCompositeEndpoint-30-dayDeath,Reinfarction,DisablingStrokeBonne

foyE,etal.Lancet2002;360:825-9AMIwithin6hours1200planned840enrolledPrehospitalThrombolysisn=419PrimaryAngio

plastyn=421ComparisonofAngioplastyandPrehospitalThrombolysisinAcuteMyocardialInfarction2021/01/21273.84.83.71.718.231.60

5101520253035DeathRe-MIStrokeCompositePrehosplysisN=419PrimaryPTCAN=421ThrombolysisorPCIinAMICAPTIM:StudyDesignP=0.61P=0.13P=0.12P=0.29BonnefoyE,eta

l.Lancet2002;360:825-9PrimaryPTCAwasnotbetterthanpre-hospitalthrombolysiswithtransferforpossiblerescuePTCAinptswith<6hronse

tofAMI2021/01/2128High-riskSTelevationMIpatients(>4mmelevation),Sx<12hrs5PCIcenters(n=443)and22referringhospitals(n

=1,129),transferin<3hrsLytictherapyFront-loadedtPA100mg(n=782)Death/Re-MI/Strokeat30DaysThrombolysisorPCIinAMIDANAMI-2:Study

DesignPrimaryPCIwithtransfer(n=567)PrimaryPCIwithouttransfer(n=223)StoppedearlybysafetyandefficacycommitteeAndersonHRetalNEJM20

03;349:733-422021/01/212914%8%0%4%8%12%16%Death/MI/Stroke(%)LyticPrimaryPCIP=0.0003P=0.002CombinedTransferSitesP=0.048Non-TransferSitesThrombol

ysisorPCIinAMIDANAMI-2:PrimaryResultsRRR45%LyticPrimaryPCILyticPrimaryPCI14%9%0%4%8%12%16%12%7%0%4%8%12%16%RRR40%RRR45%Anderson

HRetalNEJM2003;349:733-422021/01/21302.0%1.1%0%2%4%6%8%6.3%1.6%0%2%4%6%8%7.6%6.6%0%2%4%6%8%LyticPrimaryPCIP=0.35DeathThrombolysisorPCIinAM

IDANAMI-2:ResultsLyticPrimaryPCIP=0.15StrokeLyticPrimaryPCIP<0.0001RecurrentMIAndersonHRetalNEJM2003;349:733-4296%OFPTSWERETRANSFERREDFROMREFERRALHO

SP.TOINVASIVECETNERWITHIN2HRS2021/01/2131ThrombolysisorPCIinAMIPrague2:Longdistanttransfervs.ThrombolysisinAMI•MulticenterCzechstudy

involving850ptswithSTelevationMIwithin12hrsofsymptomonset.•Primaryendpointwas30-daymoratlity,andcompositesecondaryendpointswere:death,re-MI,strokeat3

0days.WidimskyPetalEurHeartJ2003;24:94-1042021/01/2132106.87.47.315.3615.28.40246810121416PercentAllptsn=8500-3hrsn=5513-12hrsn=299c

omposite*Thrombolysisn=421PCIn=429ThrombolysisorPCIinAMIPrague2:Longdistanttransfervs.ThrombolysisinAMIP=0.12P=NSP<0.02P<0.003Forpts

within3hrsofsymptoms,thrombolysisortransferforPCIiscomparablestrategy.However,forptspresent>3hrsofsymptomonset,PCIresultsinbetterclinical

outcomedespitelongdistancetransfer.WidimskyPetalEurHeartJ2003;24:94-1042021/01/2133•TimetoPerfusion•VolumeofHos

pitalandexperienceofOperatorThrombolysisorPCIinAMIWhatElseisImportantinAMITreatmentStrategy?Additionalimportantparameterstoma

ximizequalityofcareinthetreatmentofAMIpatients2021/01/21354.24.65.16.78.57.902468100-6061-9091-120121-150151-180>180Mort

ality(%)N=27,080,P<0.00001ThrombolysisorPCIinAMINRMI-2:PrimaryPCIDoor-to-Balloontimevs.MortalityDoor-to-BalloonTime(m

inutes)2021/01/2136ThrombolysisorPCIinAMIMortalityrateswithprimaryPCIasafunctionofPCI-relatedtimedelayP=0.006

020406080100PCI-RelatedTimeDelay(door-to-balloon-doortoneedle)AbsoluteRiskDifferenceinDeath(%)-5051015Circlesizes=sam

plesizeoftheindividualstudySolidline=weightedmeta-regressionNallamothuBK,BatesER.AmJCardiol.2003;92:824-662minBenefitFavorsPC

IHarmFavorsLysisForEvery10mindelaytoPCI:1%reductioninmortalitydifferencetowardslyticsMeta-analysisof23studieswith7419pts2021/01/2137•

TimetoPerfusion•VolumeofHospitalandexperienceofOperatorThrombolysisorPCIinAMIWhatElseisImportantinAMIT

reatmentStrategy?AdditionalimportantparameterstomaximizequalityofcareinthetreatmentofAMIpatients2021/01/213800.20

.40.60.811.2<1212-36>36HospitalVolumeofPrimaryAngioplastyCasesperYearMVAdjustedOddsofDeathThrombolysisorPCIinAMINRMI-2:HospitalVolumeofP

rimaryPCIvs.MortalityN=4,74014,0788,262P=0.033P=0.00010.860.672021/01/2139•IncidenceandPatho-anatomyofAMI•Fibrinol

ysisforAMI•FibrinolysisVs.PrimaryPCI•AdjunctPharmacologyandStrategies•CurrentRecommendationsinTreatmentofAMIThr

ombolysisorPCIinAMI2021/01/2140ThrombolysisorPCIinAMIImportanceofEarlyReperfusionTherapyinSTEMIOutcomesDependentUpon:•Timetotreatment-TIM

EISSTILLMUSCLE•Earlyandfullrestorationincoronarybloodflow•Sustainedrestorationofflow2021/01/2141ThrombolysisorPCIinAMIPharmacologicalRe

perfusionAvailableResourcesClassI1.STEMIpatientspresentingtoafacilitywithoutthecapabilityforexpert,promptint

erventionwithprimaryPCIwithin90minutesoffirstmedicalcontactshouldundergofibrinolysisunlesscontraindicated

.(LevelofEvidence:A)Antmanetal.JACC2004;44:682.2021/01/2142ThrombolysisorPCIinAMIFibrinolyticTherapyCla

ssIIntheabsenceofcontraindication,fibrinolytictherapyshouldbeadministeredtoSTEMIpatientswithsymptomo

nsetwithintheprior12hours&STelevation2.Intheabsenceofcontraindications,fibrinolytictherapyshouldbeadministered

toSTEMIpatientswithsymptomonsetwithintheprior12hoursandneworpresumablynewLBBB.(LevelofEvidence:A)Antmanetal.JACC2004;44:682-

3.2021/01/2143ThrombolysisorPCIinAMIPrimaryPercutaneousCoronaryInterventionClassI1.Generalconsiderations:Theprocedureshouldbesupportedby

experiencedpersonnelinanappropriatelaboratoryenvironment(performsmorethan200PCIproceduresperyear,ofwhichatleast36areprimaryPCIforSTEMI,andhascardiac

surgerycapability).(LevelofEvidence:A)Antmanetal.JACC2004;44:682.2021/01/2144ThrombolysisorPCIinAMIPrimaryPercutaneousCoronaryI

nterventionClassI2.SpecificConsiderations:a.PrimaryPCIshouldbeperformedasquicklyaspossible,withagoalofamedicalcontact–to-balloonordoo

r-to-balloontimeofwithin90minutes.(LevelofEvidence:B)b.Ifthesymptomdurationiswithin3hoursandtheexpecteddoor-to-balloontime

minustheexpecteddoor-to-needletimeis:i)within1hour,primaryPCIisgenerallypreferred.(LevelofEvidence:B)ii)greaterthan1hour,fibrino

lytictherapy(fibrin-specificagents)isgenerallypreferred.(LevelofEvidence:B)c.Ifsymptomdurationisgreaterthan3hours,primaryPCIisgenerally

preferredandshouldbeperformedwithamedicalcontact–to-balloonordoor-to-balloontimeasbriefaspossible,withagoalo

fwithin90minutes.(LevelofEvidence:B)Antmanetal.JACC2004;44:6842021/01/2145PrimaryPercutaneousCoronaryInterventionFacilitatedPCIClassIIb1.F

acilitatedPCImightbeperformedasareperfusionstrategyinhigher-riskpatientswhenPCIisnotimmediatelyavailableandbleedingriskislow.2.(Leve

lofEvidence:B)Antmanetal.JACC2004;44:686.2021/01/2146FibrinolyticTherapyCombinationTherapywithGPIIb/IIIaClassIII1.Combinationpharmacologic

alreperfusionwithabciximabandhalf-dosereteplaseortenecteplaseshouldnotbegiventopatientsagedgreaterthan7

5yearsbecauseofanincreasedriskofICH.(LevelofEvidence:B)Antmanetal.JACC2004;44:683.2021/01/2147AdaptedfromFigure3;Antm

anetal.JACC2004;44:682Ifpresentationis<3hrsandthereisnodelaytoaninvasivestrategy,theneitherstrategyisa

cceptable.Fibrinolysisisgenerallypreferredif:•Earlypresentation(3hoursorlessfromsymptomonset&delaytoinva

sivestrategy;seebelow)•InvasivestrategyisnotanoptionCatheterizationlaboccupied/notavailableVasculara

ccessdifficultiesLackofaccesstoaskilledPCIlab-Operatorexperience>75PPCIcasesperyear/Teamexperience>36PPCIcasesperyear•Delaytoinvasives

trategyProlongedtransport(Door-toBalloon)–(Door-to-needle)timeis>1HRMedicalcontact-to-balloontimeis>than90minTh

rombolysisorPCIinAMIWhichStrategytoChoose?2021/01/2148THANKSFORWATCHING谢谢大家观看为了方便教学与学习使用，本文档内容可以在下载后随意修

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