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S.ChiuWongMD,FACCAssociateProfessorofMedicineWeillMedicalCollegeofCornellUniversityDirector,CardiacCatheterizationLaboratoriesTheNewYor

kPresbyterianHospital-CornellCampusTheACCSymposiumattheGreatWallMeeting,BeijingChinaOctober17,2004ThrombolysisorPrimaryPCIintheTrea

tmentofAcuteMI2021/01/211•Patho-anatomyofAMI•FibrinolysisforAMI•FibrinolysisVs.PrimaryPCI•AdjunctPharmacologyandStrategies•CurrentRecommendationsin

TreatmentofAMIThrombolysisorPCIinAMISummary2021/01/212•Patho-anatomyofAMI•FibrinolysisforAMI•FibrinolysisVs.PrimaryPCI•AdjunctPharmacologyandStra

tegies•CurrentRecommendationsinTreatmentofAMIThrombolysisorPCIinAMI2021/01/213Circulation,VolumeXLV,January1972.Page2

15-230CoronaryArteriesinFatalAcuteMyocardialInfarctionByWILLIAMC.ROBERTS,M.D.SUMMARYThecoronaryarteriesarediffuselyinvolvedbyatherosclerotic

plaquesinfatalacutemyocardialinfarction(AMI).Thedegreeofluminalnarrowingmayvarybutplaquesarepresentinpracticallyeverymil

limeterofextramuralcoronaryartery.Usuallythelumensofatleasttwoofthethreemajorcoronaryarteriesarenarrowed>75%byoldplaquesinpatientswhodies

uddenly(<6hours)fromcardiacdiseasewithorwithoutmyocardialnecrosis.Coronarythrombioccurinabout10%ofpatientswhodiesuddenlyorin

whomnecrosisislimitedtotheleftventricularsubendocardium,andinabout50%ofpatientswithtransmuralmyocardialnecrosis.Coro

narythrombiusuallyindicatethepresenceofshockorcongestiveheartfailureorbothduringdiedevelopmentofmyocardialnecrosis.Theinfrequencyofcor

onarythrombiinpatientsdyingsuddenlyofcardiacdiseaseandinthosewithtransmuralnecrosiswhoneverhaveshockorco

ngestiveheartfailuresuggeststhatthethrombimaybeconsequencesratherthancausesofAMI.ThrombolysisorPCIinAMIPatho-Anatom

yofAMI2021/01/214ThrombolysisorPCIinAMIPatho-AnatomyofAMI2021/01/215ThrombolysisorPCIinAMIPatho-AnatomyofAMI2021/01/216Thrombolysi

sorPCIinAMIPathophysiologyofST-ElevationMIResultsfromstabilizationofaplateletaggregateatsiteofplaquerupturebyfibrinmeshplateletRBC

fibrinmeshGPIIb-IIIaMIgenerallycausedbyacompletelyocclusivethrombusinacoronaryartery2021/01/217•IncidenceandPatho-anatomyofAMI•FibrinolysisforAMI•Fi

brinolysisVs.PrimaryPCI•AdjunctPharmacologyandStrategies•CurrentRecommendationsinTreatmentofAMIThrombolysisorPCI

inAMI2021/01/218ThrombolysisorPCIinAMIISIS-2(Secondinternationalstudyofinfarctsurvival)Randomizedtrialcomparing1MUofivst

reptokinaseover1hr,oralaspirin,both,orneitheramong17,187ptswithsuspectedAMIupto24hrsafteronsetofsymptom.Significantreductionofmortalityat35d

ayswasdemonstratedforaspirinorstreptokinase,andanadditivebeneficialeffectwiththe2combinedagentswasnoted.ISIS-2Colla

borativeGroup.Lancet1988;332:349–3602021/01/219ThrombolysisorPCIinAMIThrombolyticAgentsforAMIComprehensiveoverviewofthrombolytict

herapyonAMIonearly(5-week)mortalityfromrandomizedtrialsofmorethan1000ptsbythefibrinolyticcollaborativegroup……FCGThelancet1

994;343:311-22ThrombolyticsarebeneficialacrossabroadspectrumofAMIptswithSTEorBBBperhapswiththeexceptioninptswhowere>75yrsandtreated

>12hrsfromsxonsetwere.Theearliertreatmentinitiation,thegreaterthebenefitandthusre-affirmtheconceptof“timeismuscle.”2021/01/2110•Noteverypatientiselig

ibleforthrombolytictreatment•Cerebral/vascularbleed•PercentAMIptswithTIMI3flowfollowingthrombolysisislessthanidealThrombolysisorPCIinAMI

LimitationsofThrombolysisinAMIPatients2021/01/2111ThrombolysisorPCIinAMIContraindicationsforfibrinolyticsinAMIContraindications•Previoushemorrhagicst

rokeatanytime;otherstrokesorcerebrovasculareventswithin1yr•Knownintracranialneoplasm•Activeinternalbleeding(doesnotincludemenses)•Suspectedaort

icdissectionAdaptedfromRyanTJ,etal.ACC/AHAguidelinesforthemanagementofpatientswithAMI.JAmCollCardiol1996;28:1328–1428202

1/01/2112Relativecontraindications•Severeuncontrolledhypertensiononpresentation(bloodpressure>180/110mmHg)or

chronichistoryofseverehypertension•Historyofpriorcerebrovascularaccidentorknownintracerebralpathologynotcoveredincontraindica

tions•Currentuseofanticoagulantsintherapeuticdoses(internationalnormalizedratio2–3);knownbleedingdiathesis•Rece

nttrauma(within2–4wk),includingheadtraumaortraumaticorprolonged(>10min)cardiopulmonaryresuscitationormajorsurgery•Noncompress

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

icreaction•PregnancyandActivepepticulcerAdaptedfromRyanTJ,etal.ACC/AHAguidelinesforthemanagementofpatientswith

AMI.JAmCollCardiol1996;28:1328–1428ThrombolysisorPCIinAMIContraindicationsforfibrinolyticsinAMI2021/0

1/2113•Previouslarge-scalerandomizedthrombolyticstudieswouldsuggestthatonly15-20%ofAcuteMI(AMI)patientsarec

onsideredeligibleforreperfusiontherapybyconventionalcriteria•Morerecentobservationalstudies*withbroaderi

nclusioncriteriawouldestimatethatapproximately45to50%ofAMIptswereeligible(ie.<12hrssymptomonset,chestpainwith≥2mmST↑inany2co

ntiguousECGleadsornewLBBB)and32-45%ofptsactuallyreceivedthrombolyticagents.ThrombolysisorPCIinAMIEligi

bilityforThrombolysisinAMIPatientsKarlsonBWetalCirc1990;82:1140-6,*FrenchJKetalBMJ1996;312:1637-41*ReikvmetalIntJCardiol1997;61:79-832021/01/2114•

Noteverypatientiseligibleforthrombolytictreatment•Cerebral/vascularbleedandre-infarction•PercentAMIptswithTIMI3flowfollo

wingthrombolysisislessthanidealThrombolysisorPCIinAMILimitationsofThrombolysisinAMIPatients2021/01/2115ReteplaseN=8260Reteplase+ReoproN=832

6OR(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:Pr

imaryandSecondaryEndpoints16,588ptswithin6hrsofSTEMIrandomizedtostandarddoseofreteplase(n=8260)or½-dosereteplaseandfull-doseReopro(n=8328).Th

eGUSTOVInvestigators.Lancet2001;357:1905-142021/01/2116•Noteverypatientiseligibleforthrombolytictreatment•Cerebral/vascularbleed•Percent

AMIptswithTIMI3flowfollowingthrombolysisislessthanidealThrombolysisorPCIinAMILimitationsofThrombolysisinAMIPatients2021/01/211760605763020406080100tP

ArPANPATNK40The90MinuteWall:60%RatesofTIMIGrade3Flow%TIMI3Flow2021/01/2118•IncidenceandPatho-anatomyofAMI•FibrinolysisforAMI•FibrinolysisV

s.PrimaryPCI•AdjunctPharmacologyandStrategies•CurrentRecommendationsinTreatmentofAMIThrombolysisorPCIinAMI2021/01/2119Grin

es,C.L.etal.NEnglJMed1993;328:673-679ThrombolysisorPCIinAMIPAMI:In-HospitalReinfarctionandDeath395Ptswereenrolledin12siteswith

AMIwithin12hrsofsymptomonsetandrandomizedtoimmediatePTCA(n=195)vs.tPA(n=200)By6months,reMIordeathhadoccurredin15.8%ofptstreat

edwithtPAand8.5%treatedwithPTCA(p=0.02).2021/01/212079371281402468101214PercentDeathRE-MIStrokeCompositePTCAThrombolysisThromb

olysisorPCIinAMIShort(4-6wks)-termclinicalOutcomesPost1°PTCAVs.ThrombolysisKeeleyetal,Lancet2003;361:13-20Summaryof23

trialstotaling7,739pts(PTCA=3,872andThrombolysis=3,867pts)27%65%54%47%2021/01/2121ThrombolysisorPCIinAMIAdvantagesandDisadvantagesof1°PTCAVs.Thromb

olysisAdvantagesDisadvantagesSuperiorvesselpatencyandTIMI3flowLackofgeneralizedavailabilityEarlydefinitionofcoronaryanatomyallowsriskstra

tificationDelayinmobilizingcathlabReducedratesofrecurrentischemia,re-MI,death,andstrokeSkilledinterventionalcardiologysrequ

iredImprovedsurvivalinhighriskpatientsNolargesinglemortalitytrialdataavailableReducedintracranialbleedShorterlengthofhos

pitalstayAllowsreperfusionwhenthrombolyticsarecontra-indicated2021/01/2122•IncidenceandPatho-anatomyofA

MI•FibrinolysisforAMI•FibrinolysisVs.PrimaryPCI•AdjunctPharmacologyandStrategies•CurrentRecommendationsinTreatmentofAMIThrom

bolysisorPCIinAMI2021/01/2123ThrombolysisorPCIinAMITheADMIRALTrial•Multi-center300ptsrandomized,double-blindplacebocontrolledstudytodemons

tratethesuperiorityofabciximaboverplaceboinprimaryPTCAwithstentinginacutemyocardialinfarctionMontalescotGetalNEJM2001

;344:1895-19032021/01/2124ThrombolysisorPCIinAMIADMIRAL:FrequencyofTIMIIIIFLOW16.85.495.186.795.592.694.382.80102

030405060708090100PercentBeforeAfter24hrs6mthsReopron=149Placebon=151P=0.01P=0.04P=0.33P=0.04MontalescotGetalN

EJM2001;344:1895-19032021/01/2125ThrombolysisorPCIinAMIADMIRAL:CompositeEndpoint@6month3.47.32426.67.415.90246810121416Dea

thRe-MIUrgentTVRCompositeReopron=149Placebon=151P=0.13MontalescotGetalNEJM2001;344:1895-1903P=0.32P=0.049P=0.02Reoproimprovescor

onarypatencybeforestenting,andclinicaloutcomeat30daysand6monthsN=149N=1512021/01/2126ThrombolysisorPCIinAMICAP

TIM:StudyDesignPrimaryCompositeEndpoint-30-dayDeath,Reinfarction,DisablingStrokeBonnefoyE,etal.Lancet2002;

360:825-9AMIwithin6hours1200planned840enrolledPrehospitalThrombolysisn=419PrimaryAngioplastyn=421ComparisonofAngioplastyandPrehospitalThrombo

lysisinAcuteMyocardialInfarction2021/01/21273.84.83.71.718.231.605101520253035DeathRe-MIStrokeCompositePrehosplysis

N=419PrimaryPTCAN=421ThrombolysisorPCIinAMICAPTIM:StudyDesignP=0.61P=0.13P=0.12P=0.29BonnefoyE,etal.Lancet2002;360:825-9Pri

maryPTCAwasnotbetterthanpre-hospitalthrombolysiswithtransferforpossiblerescuePTCAinptswith<6hronsetofAMI2021/01/2128High-riskSTelevationMIpatients(>4

mmelevation),Sx<12hrs5PCIcenters(n=443)and22referringhospitals(n=1,129),transferin<3hrsLytictherapyFront-loadedtPA100mg(n=782)

Death/Re-MI/Strokeat30DaysThrombolysisorPCIinAMIDANAMI-2:StudyDesignPrimaryPCIwithtransfer(n=567)PrimaryPCI

withouttransfer(n=223)StoppedearlybysafetyandefficacycommitteeAndersonHRetalNEJM2003;349:733-422021/01/212914%8%0%4%8%12%16%Death/MI/S

troke(%)LyticPrimaryPCIP=0.0003P=0.002CombinedTransferSitesP=0.048Non-TransferSitesThrombolysisorPCIinAMIDANAMI-2:PrimaryResultsRRR45%LyticPrima

ryPCILyticPrimaryPCI14%9%0%4%8%12%16%12%7%0%4%8%12%16%RRR40%RRR45%AndersonHRetalNEJM2003;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=0.35DeathThrombolysisorPCIinAMIDANAMI-2:Result

sLyticPrimaryPCIP=0.15StrokeLyticPrimaryPCIP<0.0001RecurrentMIAndersonHRetalNEJM2003;349:733-4296%OFPTSWERET

RANSFERREDFROMREFERRALHOSP.TOINVASIVECETNERWITHIN2HRS2021/01/2131ThrombolysisorPCIinAMIPrague2:Longdis

tanttransfervs.ThrombolysisinAMI•MulticenterCzechstudyinvolving850ptswithSTelevationMIwithin12hrsofsymptomonset.•Primary

endpointwas30-daymoratlity,andcompositesecondaryendpointswere:death,re-MI,strokeat30days.WidimskyPetalEurHeartJ2

003;24:94-1042021/01/2132106.87.47.315.3615.28.40246810121416PercentAllptsn=8500-3hrsn=5513-12hrsn=299composite*Thrombolysisn=421P

CIn=429ThrombolysisorPCIinAMIPrague2:Longdistanttransfervs.ThrombolysisinAMIP=0.12P=NSP<0.02P<0.003Forptswithin3hrsofsymptoms

,thrombolysisortransferforPCIiscomparablestrategy.However,forptspresent>3hrsofsymptomonset,PCIresultsinbetterclinicalout

comedespitelongdistancetransfer.WidimskyPetalEurHeartJ2003;24:94-1042021/01/2133•TimetoPerfusion•Volumeo

fHospitalandexperienceofOperatorThrombolysisorPCIinAMIWhatElseisImportantinAMITreatmentStrategy?Additionalimportantparamete

rstomaximizequalityofcareinthetreatmentofAMIpatients2021/01/21354.24.65.16.78.57.902468100-6061-9091-120121-150151-18

0>180Mortality(%)N=27,080,P<0.00001ThrombolysisorPCIinAMINRMI-2:PrimaryPCIDoor-to-Balloontimevs.MortalityDoor-to-BalloonTime(minute

s)2021/01/2136ThrombolysisorPCIinAMIMortalityrateswithprimaryPCIasafunctionofPCI-relatedtimedelayP=0.0060204060801

00PCI-RelatedTimeDelay(door-to-balloon-doortoneedle)AbsoluteRiskDifferenceinDeath(%)-5051015Circlesizes=samplesizeoftheindividualstudySo

lidline=weightedmeta-regressionNallamothuBK,BatesER.AmJCardiol.2003;92:824-662minBenefitFavorsPCIHarmFavorsLysisForEvery10mindelayt

oPCI:1%reductioninmortalitydifferencetowardslyticsMeta-analysisof23studieswith7419pts2021/01/2137•TimetoPerfusion•V

olumeofHospitalandexperienceofOperatorThrombolysisorPCIinAMIWhatElseisImportantinAMITreatmentStrategy?Additionalimportantpara

meterstomaximizequalityofcareinthetreatmentofAMIpatients2021/01/213800.20.40.60.811.2<1212-36>36Hospital

VolumeofPrimaryAngioplastyCasesperYearMVAdjustedOddsofDeathThrombolysisorPCIinAMINRMI-2:HospitalVolumeofPrimaryPCIvs.Mortal

ityN=4,74014,0788,262P=0.033P=0.00010.860.672021/01/2139•IncidenceandPatho-anatomyofAMI•Fibrinolysisf

orAMI•FibrinolysisVs.PrimaryPCI•AdjunctPharmacologyandStrategies•CurrentRecommendationsinTreatmentofAMIThromb

olysisorPCIinAMI2021/01/2140ThrombolysisorPCIinAMIImportanceofEarlyReperfusionTherapyinSTEMIOutcomesDependentUpon:•Timetotrea

tment-TIMEISSTILLMUSCLE•Earlyandfullrestorationincoronarybloodflow•Sustainedrestorationofflow2021/01/2141ThrombolysisorPCIi

nAMIPharmacologicalReperfusionAvailableResourcesClassI1.STEMIpatientspresentingtoafacilitywithoutthecapabilityfo

rexpert,promptinterventionwithprimaryPCIwithin90minutesoffirstmedicalcontactshouldundergofibrinolysisunlesscontraindicated.(LevelofEvi

dence:A)Antmanetal.JACC2004;44:682.2021/01/2142ThrombolysisorPCIinAMIFibrinolyticTherapyClassIIntheabsenceofcontraindication,fibri

nolytictherapyshouldbeadministeredtoSTEMIpatientswithsymptomonsetwithintheprior12hours&STelevation2.Intheabsenceofcontr

aindications,fibrinolytictherapyshouldbeadministeredtoSTEMIpatientswithsymptomonsetwithintheprior12hoursandneworpresumablynewLBBB.(LevelofEvi

dence:A)Antmanetal.JACC2004;44:682-3.2021/01/2143ThrombolysisorPCIinAMIPrimaryPercutaneousCoronaryInterventionClassI1.Generalconsi

derations:Theprocedureshouldbesupportedbyexperiencedpersonnelinanappropriatelaboratoryenvironment(performsmorethan200PCIpro

ceduresperyear,ofwhichatleast36areprimaryPCIforSTEMI,andhascardiacsurgerycapability).(LevelofEvidence:A)An

tmanetal.JACC2004;44:682.2021/01/2144ThrombolysisorPCIinAMIPrimaryPercutaneousCoronaryInterventionClassI2.SpecificCo

nsiderations:a.PrimaryPCIshouldbeperformedasquicklyaspossible,withagoalofamedicalcontact–to-balloonordoor-to-balloontimeofwithin90minut

es.(LevelofEvidence:B)b.Ifthesymptomdurationiswithin3hoursandtheexpecteddoor-to-balloontimeminustheex

pecteddoor-to-needletimeis:i)within1hour,primaryPCIisgenerallypreferred.(LevelofEvidence:B)ii)greaterthan1hour,fibrinolytictherapy(fibrin-s

pecificagents)isgenerallypreferred.(LevelofEvidence:B)c.Ifsymptomdurationisgreaterthan3hours,primaryPCIisgenerallypreferredandshouldbeperformedwitha

medicalcontact–to-balloonordoor-to-balloontimeasbriefaspossible,withagoalofwithin90minutes.(LevelofEvidence:B)An

tmanetal.JACC2004;44:6842021/01/2145PrimaryPercutaneousCoronaryInterventionFacilitatedPCIClassIIb1.FacilitatedPCImightbeperformedasareperfusionstra

tegyinhigher-riskpatientswhenPCIisnotimmediatelyavailableandbleedingriskislow.2.(LevelofEvidence:B)Antmanetal.

JACC2004;44:686.2021/01/2146FibrinolyticTherapyCombinationTherapywithGPIIb/IIIaClassIII1.Combinationpharmacologicalreperfusionwithabciximabandh

alf-dosereteplaseortenecteplaseshouldnotbegiventopatientsagedgreaterthan75yearsbecauseofanincreasedriskofICH.(LevelofEvidence:B)A

ntmanetal.JACC2004;44:683.2021/01/2147AdaptedfromFigure3;Antmanetal.JACC2004;44:682Ifpresentationis<3hrsandthereisnodelaytoaninvasivestrategy,t

heneitherstrategyisacceptable.Fibrinolysisisgenerallypreferredif:•Earlypresentation(3hoursorlessfromsymptomonset&delaytoinva

sivestrategy;seebelow)•InvasivestrategyisnotanoptionCatheterizationlaboccupied/notavailableVascularaccessdif

ficultiesLackofaccesstoaskilledPCIlab-Operatorexperience>75PPCIcasesperyear/Teamexperience>36PPCIcasesperyear•

DelaytoinvasivestrategyProlongedtransport(Door-toBalloon)–(Door-to-needle)timeis>1HRMedicalcontact-to-balloonti

meis>than90minThrombolysisorPCIinAMIWhichStrategytoChoose?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改，调整。欢迎下载！时间：2

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