急性心肌梗死直接PCI

ACCF/AHA/SCAI关于AMI直接PCI指南解析YidaTang,MD,PhDDept.ofCardiology,FuwaiHospitalChineseAcademyofMedicalSciencesNationalCenterforCardiovascularDisease•2010ESCcoronaryrevascularizationguideline•2011ACCAHAPCIguideline•2012ACCAHANSTEMIguideline•2012ESCDefinitionofMIGuideline•2012ESCNSTEMIGuideline•2013ACCAHAdefinitionofMI•2013ACCAHASTEMIguideline•2013ESCSTEMIGuidelineClassofRecommendation(COR)CORBenefit/RiskKeyWords(Theprocedureortreatment…)ClassIBenefitRisk•Shouldbeperformed/administered•Isrecommended•Isindicated•Isuseful/effective/beneficialClassIIaBenefitRisk•Isreasonable•Canbeuseful/effective/beneficial•IsprobablyrecommendedorindicatedClassIIbBenefit≥Risk•May/mightbeconsideredorbereasonable•Usefulness/effectivenessisunknown/unclear/uncertainornotwellestablishedClassIII–NoBenefit•Nothelpful•Noprovenbenefit•Isnotrecommended/indicated•Shouldnotbeperformed/administered•Isnotuseful/beneficial/effectiveClassIII–Harm•Harmful•Excesscostwithoutbenefitorharmful•Potentiallyharmful•Causesharm•Shouldnotbeperformed/administeredGNL2011LevelofEvidence(LOE)LOECriteriaA•Multiplepopulationsevaluated•Dataderivedfrommultiplerandomizedclinicaltrialsormeta-analysesB•Limitedpopulationsevaluated•DataderivedfromasinglerandomizedtrialornonrandomizedstudiesC•Verylimitedpopulationsevaluated•Onlyconsensusopinionofexperts,casestudies,orstandardofcareGNL2011STEMI急诊PCI方式•直接(primary,direct)PCI：不溶栓直接行PCI•补救(rescue,salvage)PCI：溶栓失败后行PCI•即刻(immediate)PCI：溶栓成功对严重残余狭窄行PCI•延迟(delayed,deferred)PCI：溶栓后1-7天行PCIPCIinSTEMI*IndicationsCORLOEPrimaryPCI*STEMIsymptomswithin12hIASevereheartfailureorcardio-genicshockIBContraindicationstofibrinolytictherapywithischemicsymptoms12hIBClinicaland/orECGevidenceofongoingischemiabetween12and24haftersymptomonsetIIaBAsymptomaticpatientpresentingbetween12and24haftersymptomonsetandhigherriskIIbCNoninfarctarteryPCIatthetimeofprimaryPCIinpatientswithouthemodynamiccompromiseIII:HarmBDelayedorElectivePCIinPatientswithSTEMI(i.e.Non-PrimaryPCI)ClinicalevidenceforfibrinolyticfailureorinfarctarteryreocclusionIIaBPatentinfarctartery3to24hafterfibrinolytictherapyIIaBIschemiaonnoninvasivetestingIIaBHemodynamicallysignificantstenosisinapatentinfarctartery24hoursafterSTEMIIIbBTotallyoccludedinfarctartery24hafterSTEMIinahemodyamicallystableasymptomaticpatientwithoutevidenceofsevereischemiaIII:NoBenefitBGNL2011新版PCI指南的要点分析作为整体目标，应当在STEMI发生后12小时内并且在首次医疗接触后90分钟内实施直接PCICardiogenicShockRecommendationCORLOEImmediatecoronaryangiographyinpatientswithSTEMIwithsevereheartfailureorcardiogenicshockwhoaresuitablecandidatesforrevascularizationIBPCIforpatientswithacuteMIwhodevelopcardiogenicshockandaresuitablecandidatesIBHemodynamicsupportdeviceforpatientswithcardiogenicshockafterSTEMIwhodonotquicklystabilizewithpharmacologicaltherapyIBGNL2011•IABP应用率：13.5%•心源性休克或严重低血压状态•No-reflow•心肺复苏•最大可能保障IRA开通新版PCI指南的要点分析STEMI并发心源性休克者，若能耐受，尽早行冠脉造影药物稳定血流动力学困难者尽早行IABP支持UA/NSTEMI:ChoiceofStrategy*RecommendationCORLOEAnearlyinvasivestrategy**inpatientswhohaverefractoryanginaorhemodynamicorelectricalinstability(withoutseriouscomorbiditiesorcontraindicationstosuchprocedures)IBAnearlyinvasivestrategy**ininitiallystabilizedpatients(withoutseriouscomorbiditiesorcontraindicationstosuchprocedures)whohaveanelevatedriskforclinicaleventsIATheselectionofPCIorCABGasthemeansofrevascularizationinthepatientwithACSshouldgenerallybebasedonthesameconsiderationsasthosewithoutACSIBAconservativestrategyrecommended(overanearlyinvasivestrategy)inwomenwithlow-riskfeaturesIBAnearlyinvasivestrategy(within12to24hoursofadmission)chosenoveradelayedinvasivestrategyforinitiallystabilizedhigh-riskpatients***IIaBAninitialconservative(i.e.,aselectivelyinvasive)strategyininitiallystabilizedpatientswhohaveanelevatedriskforclinicalevents(includingtroponinpositivepatients)***IIbCAnearlyinvasivestrategy**inpatientswithextensivecomorbiditiesinwhomtherisksofrevascularizationandcomorbidconditionsarelikelytooutweighthebenefitsofrevascularization,inpatientswithacutechestpainandalowlikelihoodofACS,orinpatientswhowillnotconsenttorevascularizationregardlessofthefindingsIII–NoBenefitCGNL2011优选介入治疗首先优选药物治疗RecurrentanginaorischemiaatrestorwithlowlevelactivitiesdespiteintensivemedicaltherapyElevatedcardiacbiomarkers(TnTorTnI)NeworpresumablynewST-depressionSignsorsymptomsofheartfailureHemodynamicinstabilityHighriskscore(e.g.,GRACE,TIMI)SustainedventriculartachycardiaPCIwithin6moPriorCABGDiabetesmellitusMildtomoderaterenaldysfunctionReducedLVfunction(LVEF40%)Lowriskscore(e.g.,GRACE,TIMI)Absenceofhigh-riskfeaturesHighriskforcatheterization-relatedcomplicationsPatientnotarevascularizationcandidate(witheitherPCIorCABG)PatientprefersconservativetherapyGNL2011新版PCI指南要点分析NSTEMIUPLMPCItoImproveSurvival(ACS)CORLOEIIaForUA/NSTEMIifnotaCABGcandidateBIIaForSTEMIwhendistalcoronaryflowisTIMIgrade3andPCIcanbeperformedmorerapidlyandsafelythanCABGCGNL2011新版PCI指南的要点分析对于无保护左主干是罪犯病变并且冠脉远端血流不足TIMI3级的急性STEMI患者，PCI可以提高存活，并且与CABG比较，可迅速和安全实施PCIUPLMRevascularizationtoImproveSurvivalRevascMethodCORLOECABGIBPCIIIaForSIH