急性心肌梗死诊断和治疗指南

:,,10003720,(AMI),,,,(ACC/AHA)1999AMI,,AMI,STST,,,,ACC/AHA:I:();II:;IIa:()();IIb:()();III:(),,,AMIAMI,,AMI,,,AMI()AMI10min,18(12V7V9V3RV5R),30min90min(PTCA)()AMIAMI,AMI11.:AMI,;,20min,,,,2.18:10min18STAMI91%,46%18(1)ST0172001122912ChinJCardiol,December2001,Vol.29No.12©1995-2005TsinghuaTongfangOpticalDiscCo.,Ltd.Allrightsreserved.,,,(30min90min),1AMI(2)ST,(STT),,,()(3),,,,AMI,,,()AMI1.AMI::(1);(2);(3)ST,,,(2)AMIT,,,:+22.:AMI11AMIcTnIcTnTCKCK2MBAST3(h)122424634612100%(h)48812812812(h)48102410242410242448(d)0151510514342435:3(ALT),ASTALT;CK:;CK2MB:;AST:(AST)(CK)(CK2MB)AMI,,(ALTAST),,,CK2MBI(cTnI)T(cTnT),cTnTcTnI,1172001122912ChinJCardiol,December2001,Vol.29No.12©1995-2005TsinghuaTongfangOpticalDiscCo.,Ltd.Allrightsreserved.,CK2MBCK,2AMI,,,,AMI24h69h1224h,,,,,CK2MB,AMIAMI18ST,(70),STSTAMIST,Q,ST,2,,ST,30%cTnIcTnT,Q,CK2MB,,CKcTnIcTnT,AMI50%1h,,AMI:(1);(2),,AMIAMI,;,,AMIAMIAMI,:(1);(2)1(016mg),5min3,,24h,,,AMI[(100mmHg,1mmHg=0.133kPa)(100/min)],AMI,1020min118STAMI,30min(CCU),90minPTCASTAMI,STAMI()AMI,,AMI1.:,2.:,AMI13d,2172001122912ChinJCardiol,December2001,Vol.29No.12©1995-2005TsinghuaTongfangOpticalDiscCo.,Ltd.Allrightsreserved.3.:4.:AMI,,,,,3mg,5min1,15mg,3min014mg(3)5.:AMI,,/,,6.:AMI2448h,,,,,(90mmHg)(50/min)(100/min),7.:AMI150300mg8.9.:AMIAMI,015110mg,35min,215mg(015mg)101:AMI,,AMI,()1.:2080,,,STAMI,,6h,,,AMI,,612hST(1):ST(012mV,011mV),AMI(ST),12h,75(ACC/AHAI)(100mmHg)(100/min)ST,75,,AMI,7575,,75AMI100010,,(ACC/AHAIIa)ST,1224h,,ST,(ACC/AHAIIb),180mmHg()110mmHg,,(),150/90mmHg,PTCA(ACC/AHAIIb)ST,24h,ST(ACC/AHAIII)(2):,1;;(24)();3172001122912ChinJCardiol,December2001,Vol.29No.12©1995-2005TsinghuaTongfangOpticalDiscCo.,Ltd.Allrightsreserved.;(180/110mmHg);[(INR)23],;(24),(10min);(3);(2);(5d2),;lv;lw(3)::,,150U30min,750010000U,12h,,2:,150U1h,750010000U,12h,,2(rt2PA):(GUSTO),15mg,30min0175mg/kg(50mg),60min015mg/kg(35mg)5000U,1000U/h,aPTT,aPTT6080s,TUCC(rt2PAandurokinasecomparisoninChina,rt2PA),50mgrt2PA(8mg,42mg90min,,),,90min(7913%vs5310%,P=01001),2.:(1)PTCA:PTCA,(IRA),(TIMI)3,,,()Weaver10PTCA(2606AMI),30dPTCA(414%vs1119%,P0101),PTCA(017%vs210%,P=01007)(011%vs111%,P01001),PTCA,PTCAAMISHOCK(Shouldweemergentlyrevascularizeoccludedcoronariesforcardiogenicshock??),AMI,PTCA(),6(5013%vs6311%,P=01027);751514%(P=0101),75PTCA:a.STAMI,PTCA,PTCA12h12h,PTCA(ACC/AHAI):90min:PTCA30/:PTCA100/,:AMIPTCA90%;(CABG);,PTCA85%b.ST/QAMI,75,AMI36h,18h,PTCA(ACC/AHAI)c.,PTCA(ACC/AHAIIa)d.AMIST,(TIMI2),12h4172001122912ChinJCardiol,December2001,Vol.29No.12©1995-2005TsinghuaTongfangOpticalDiscCo.,Ltd.Allrightsreserved.PTCA(ACC/AHAIIb):a.AMIPTCA;b.12h,PTCAc.PTCA,,,,AMI,ZwolleSTENTPAMI(Stentprimaryangioplastyinacutemyocardialinfarction,)CADILLAC(Controlledabciximabanddeviceinvestigationtolowerlateangioplastycomplications,)PTCA,PTCA(bail2outstenting),,AMI(2)PTCA:PTCAPTCA,,RESCUE(PTCA)151(TIMI01)PTCA,PTCA30d(EF)(45%vs40%,P=0104);IIIIV(614%vs1616%,P=0105),ST,,,TIMI02PTCA,12h(3)PTCA:PTCA,TIMIIIA(ThrombolysisinmyocardialinfarctionIIA,IIA)(2h)(1848h)PTCA,(CABG),TAMI(Thrombolysisandangioplastyinmyocardialinfarction,)(90min)710dPTCA,1EF,,18%PTCA,,PTCA,,,710d,PTCA()11:,,,,,,,,,52(isosorbide252mononitrate,ISMN),AMI,AMI2448hAMI,10g/min,,510min510g,10mmHg30mmHg90mmHg,100g/min,,AMI2448h,24h,24h27mg/h,30g/min,30min,5172001122912ChinJCardiol,December2001,Vol.29No.12©1995-2005TsinghuaTongfangOpticalDiscCo.,Ltd.Allrightsreserved.5-1020mg,34,5-2040mg,2AMI(90mmHg)(100/min),21:AMI,AMI,(clopidogrel)(1):A2(A2,TXA2),,10%,,70%,12h,AMI,150300mg/d,3d50150mg/d(2)(clopidogrel):,ADP2448h,35d250mg,2,12250mg,1,(AMI),AMI,,ADP,,,,300mg,75mg/d31:,X(1):,STAMI,,STAMI,5000U,1000U/h,46h1aPTTACT,,1152104872h,7500U12h,23d,,AMI,rt2PA,,,,5000U,1000U/h48h,aPTTACT()48h7500U2,23d,,VVIII,,,6haPTTACT,aPTT2(70s),,,,(2):,40006500,Xa24,IIa,1Xa,ESSENCE(EfficacyandsafetyofsubcutaneousenoxaparininnonQwavecoronaryevents,Q)TIMI11BFRAXIS(Fraxiparininischemicsyndrome,)6172001122912ChinJCardiol,December2001,Vol.29No.12©1995-2005TsinghuaTongfangOpticalDiscCo.,Ltd.Allrightsreserved.,,,,41:,,,,2,2550mg,23,612525mg,2,,AMI,,5mg/,5min12,2AMI:60/min;100mmHg;(KillipIII);PR0124s;;:;;51(ACEI):ACEIISIS24(Internationalstudyofinfarctsurvival24,24)GISSI23(GruppoItalianoperlostudiodellastreptochinasinellinfartomiocardico23,23)SMILE(Survivalofmyocardialinfarctionlongtermevaluation,)CCS-1(Chinacardiacstudy21,21)AMIACEI,6,,ACEIACEI,,AMIACEI,6125mg,1215mg25mg,121525mg,2346AMI,ACEI;AMI,ACEIACEI:AMI90mmHg;(265mol/L);;ACEI;61:AMI,AMIQQ2,,,,,AMI(1):QAMI,,AMI,,,10mg(5min),515gkg-1min-1,,55/min,,48h,AMIAMI(90mmHg),(2):AMI,,,,AMI,71:AMI24h,AMI24h,AMIACEI,AMI,,014mg,012014mg,81:(1):AMI,7172001122912ChinJCardiol,December2001,Vol.29No.12©1995-2005TsinghuaTongfangOpticalDiscCo.,Ltd.Allrightsreserved.,198419917,AMI1991ISIS24,AMI,,:AMI,AMIQT(2)--(GIK):AMI1962,ECLA(Glucoseinsulinpotassiumpilottrial,22)GIK(25%+50IU/L+80mmol/L,115mlkg-1h-124h)GIK(10%+20IU/L+50mmol/L,1mlkg-1h-1)AMI,AMIGIK()11:AMI,,(SV)(CO),AMI(PCWP)18mmHg(CI)215Lmin-1m-2PCWP18mmHgCI212Lmin-1m-280mmHg,CI118Lmin-1m-2,PCWP20mmHg,X