阻滞剂在PCI术的应用.ppt

β受体阻滞剂在受体阻滞剂在PCI的应用的应用β受体阻断剂在非心脏手术期间的使用一直受到重视!但是在PCI围术期间的使用？2009 Focused Updates: ACC/AHA Guidelines for the Management of Patients With ST-Elevation Myocardial Infarction.2007 Focused Update of the ACC/AHA/SCAI 2005 Guideline Update for Percutaneous Coronary Intervention..Antithrombotic：： 1. UH, LMWH 2. GP IIb/IIIa Inhibitors 3. Bivalirudinstatin ？？β-block？？Antiplatelet：： 1. Aspirin 2. clopidogrel β受体阻断剂在受体阻断剂在PCI围术期间的使用围术期间的使用•术前术前•术中术中•术后术后PCI术前使用术前使用β阻滞剂减少术后阻滞剂减少术后CK-MB的上升的上升Samin K. Sharma, Annapoorna Kini, Jonathan D. Marmur,et al. Cardioprotective Effect of Prior ß-Blocker Therapy in Reducing Creatine Kinase-MB Elevation After Coronary Intervention . Circulation. 2000,102:166 -172PCIPCI术前使用术前使用ββ阻滞剂与未使用组术后阻滞剂与未使用组术后CK-MBCK-MB增高的发生率及增高程度比较增高的发生率及增高程度比较术前使用术前使用β阻滞剂对阻滞剂对AMI PCI术后临床预后的影响术后临床预后的影响Harjai KJ, Stone GW, Boura J, et al. Effects of prior beta-blocker therapy on clinical outcomes after primary coronary angioplasty for acute myocardial infarction. Am J Cardiol 2003;91:655–60.AMI PCI术前使用BB与未使用两组术后并发症、住院期间及一年随访临床预后的比较AMI PCI术前静注术前静注β阻滞剂提高术后生存率阻滞剂提高术后生存率Amir Halkin , Cindy L. Grines , David A. Cox ,et.al.Impact of intravenous Beta-Blockade before primary angioplasty on survival in patients undergoing mechanical reperfusion therapy for acute myocardial infarction. J Am Coll Cardiol, 2004; 43:1780-1787 . 术前静脉注射BB与未注射组随访三个月及一年生存率的比较RABBIT II 研究研究 PCI术中冠状动脉内注射术中冠状动脉内注射β阻滞剂减少术后不良事件发生率阻滞剂减少术后不良事件发生率Barry F Uretsky; Ernst R Schwarz; Abdulfatah Osman ,et al.Intracoronary Beta Blockade (BB) During Percutaneous Coronary Intervention (PCI): 30 Day Results of the Randomized Angioplasty Beta Blocker Intracoronary Trial II (RABBIT II). Circulation. 2006;114:II_547 急性心肌梗死急性心肌梗死PCI术后使用术后使用β阻滞剂对临床预后的影响阻滞剂对临床预后的影响Steven J. Kernis, Kishore J. Harjai, Gregg W. Stone, et.al. Does beta-blocker therapy improve clinical outcomes of acute myocardial infarction after successful primary angioplasty?JACC,43（10）:1773 - 1779.术后使用术后使用BB组较未使用组显著降低死亡率及主要心脏不良事件率组较未使用组显著降低死亡率及主要心脏不良事件率择期择期PCI后使用后使用β阻滞剂减少一年死亡率阻滞剂减少一年死亡率 PCI术后使用术后使用BB与未使用组随访一年生存率的比较与未使用组随访一年生存率的比较.P=0.0014.Albert W. Chan, Martin J. Quinn, Deepak L. Bhatt, et.al, Mortality Benefit of Beta-Blockade After Successful Elective Percutaneous Coronary Intervention. Journal of the American College of Cardiology.2002,40(4)670-675.Am Heart J 2003;145:875-81Conclusions -Adrenergic receptor blockers prescribed after PCI reduced the risk of clinical restenosis, target lesion restenosis, and MACE in this cohort of 4840 patients. The mechanism by which -blockers conferred a protective effectagainst restenosis remains to be determined. (Am Heart J 2003;145:875-81.)PCI术后长期使用β受体阻断剂可以明显减少再狭窄及临床事件！围围PCI期间使用期间使用β受体阻断剂基于以下几个方面受体阻断剂基于以下几个方面•抗炎与稳定斑块抗炎与稳定斑块•心肌保护心肌保护•预防再狭窄！？预防再狭窄！？These findings suggest that metoprolol could inhibit the development of atherosclerosis and stabilize vulnerable plaque by regulation of lipid and reduction of inflammation, in which the change from low shear stress to physiological shear stress around plaque may play an important role.Conclusions: The intravenous administration of metoprolol before coronary reperfusion results in larger myocardial salvage than its oral administration initiated early after reperfusion. If confirmed in the clinical setting, the timing and route of β-blocker initiation could be revisited.结论：术前尽早静脉使用倍他乐克可以挽救更多的心肌！问题是：β受体阻断剂的使用远远不足！Use of β-blockers and effects on heart rate and blood pressure post-acute coronary syndromes: Are we on target?Results Only 5.3% achieved an average HR of 50 to 60 beat/min throughout the hospital stay. Conclusions Although effective levels of BP were maintained during hospitalization for an ACS, target HRs were generally not achieved. (Am Heart J 2009;158:378-85.)小小 结结•β受体阻滞剂是冠心病药物治疗的基石，不仅改善症受体阻滞剂是冠心病药物治疗的基石，不仅改善症状且能改善预后状且能改善预后•PCI术围手术期使用术围手术期使用β受体阻滞剂可减少并发症、改受体阻滞剂可减少并发症、改善患者预后；减轻围手术期的心肌微损伤，潜在地善患者预后；减轻围手术期的心肌微损伤，潜在地减少再狭窄。

减少再狭窄•临床上临床上β受体阻滞剂的使用相当不足！受体阻滞剂的使用相当不足！三种临床特征相似且相互关联的情况组成三种临床特征相似且相互关联的情况组成•主动脉夹层主动脉夹层 （（AD））•主动脉壁内血肿主动脉壁内血肿 （（IMH））•穿透性溃疡穿透性溃疡 （（PAU）） 急性主动脉综合征急性主动脉综合征常见症状：胸痛 2010 ACCF/AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM Guidelines for the Diagnosis and Management of Patients with Thoracic Aortic DiseaseDeveloped in partnership with the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, American Association for Thoracic Surgery, American College of Radiology, American Stroke Association, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, Society of Interventional Radiology, Society of Thoracic Surgeons, and Society for Vascular Medicine. Endorsed by the North American Society for Cardiovascular Imaging.初期治疗建议（初期治疗建议（ I 类）类）胸主动脉夹层初始治疗应控制心率和血压，达到降低主动脉壁应力胸主动脉夹层初始治疗应控制心率和血压，达到降低主动脉壁应力目的：目的：•如无禁忌症，静脉内如无禁忌症，静脉内β阻滞剂，目标心率阻滞剂，目标心率≤60次次/分分•β阻滞剂明确禁忌症，采用非二氢吡啶类钙通道阻滞剂控制心率阻滞剂明确禁忌症，采用非二氢吡啶类钙通道阻滞剂控制心率•如在如在充分控制心率充分控制心率后后SBP ›120mmHg，静脉内用，静脉内用ACEI/或其他血管扩张剂，或其他血管扩张剂，在维持充分的终末器官灌注基础上进一步降低血压在维持充分的终末器官灌注基础上进一步降低血压•硝普钠是疗效最确切药物，可快速地逐步增高剂量以达到最佳血压控制硝普钠是疗效最确切药物，可快速地逐步增高剂量以达到最佳血压控制 •如有急性主动脉瓣返流，应慎用如有急性主动脉瓣返流，应慎用β阻滞剂，避免阻断代偿性心动过速阻滞剂，避免阻断代偿性心动过速。