急性心肌梗塞战略.ppt

AMI StrategyHow to Achieve Door-to-Balloon Times of 90 Minutes and What to Do Next? Aaron Kugelmass, MD Director, Cardiac Cath Lab Associate Division Chief Henry Ford Hospital Detroit, Michigan, USA Overview Introduction The Argument for Primary PCI Overview of the Henry Ford Program Program Specifics Process Dictates Outcomes Alternative Opportunities Acute MI: Introduction 1.1 million people yearly in the US* About 500,000 have STEMI 220,000 die from their AMI 50% of deaths in the first hour Outlook of hospitalized patients better Acute MI: Early ManagementReperfusion Pharmacological (Thrombolysis) Fibrinolytics Antithrombins Platelet Inhibitors Mechanical (Direct/Primary PCI) Angioplasty Stent Thrombectomy Combined ? Facilitated PCI Acute MI: Direct PCIAdvantages Rapid assessment of anatomy and hemodynamics TIMI-3 flow rates 75-95% in infarct artery Low incidence of hemorrhagic stroke Can be done in patients with contraindications for thrombolysis Results superior to thrombolytics in randomized trials Direct PTCA vs. ThrombolysisPAMI-1 Primary Angioplasty vs. Thrombolysis: Meta-analysis Primary Angioplasty vs. Thrombolysis: Meta-analysis PCI vs Lysis Meta Analysis Acute MI: Direct PCILimitations Only 20% of US hospitals have cath labs and fewer have PTCA facilities To achieve results similar to randomized trials the following has to be met: PTCA within 90 minutes of presentation Skilled operator (75 cases/year) Skilled lab (200 cases/year) Surgical back up necessary Is Time as Critical in Primary PCI? ACC/AHA Recommendations for Direct PCI in AMI2004 Class I General: Patients presenting within 12 hours; if performed in a timely fashion by individuals skilled in the procedure and supported by experienced personnel in high volume centers Specific: Door To Balloon Time 90 min 3hours symptom, PCI if treatment 1 hour, lytics if 1 hour Symptom 3 hours, PCI preferred 90min Within 36 hours of MI when patient develops cardiogenic shock, is 75 years and re