ACEI在STEMI指南地位.pptx

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1、主要内容2013版ACC/AHA STEMI指南主要变化ACEI在ACC/AHA STEMI指南中的基石地位FAMIS：第三代ACEI蒙诺在急性心梗中的研究第1页/共47页2013 ACCF/AHA Guideline for the Management of ST-Elevation Myocardial InfarctionDeveloped in Collaboration with American College of Emergency Physicians and Society for Cardiovascular Angiography and Interventions

2、American College of Cardiology Foundation and American Heart Association,Inc.2013 ACCF/AHA Guideline for the Management of ST-Elevation Myocardial Infarction(Journal of the American College of Cardiology).Published on December 17,2012第2页/共47页Reperfusion Therapy for Patients with STEMI*Patients with

3、cardiogenic shock or severe heart failure initially seen at a nonPCI-capable hospital should be transferred for cardiac catheterization and revascularization as soon as possible,irrespective of time delay from MI onset(Class I,LOE:B).Angiography and revascularization should not be performed within t

4、he first 2 to 3 hours after administration of fibrinolytic therapy.第3页/共47页Regional Systems of STEMI Care,Reperfusion Therapy,and Time-to-Treatment Goals All communities should create and maintain a regional system of STEMI care that includes assessment and continuous quality improvement of EMS and

5、hospital-based activities.Performance can be facilitated by participating in programs such as Mission:Lifeline and the D2B Alliance.I IIa IIb IIIPerformance of a 12-lead ECG by EMS personnel at the site of FMC is recommended in patients with symptoms consistent with STEMI.I IIa IIb III第4页/共47页第5页/共4

6、7页Primary PCI in STEMI第6页/共47页Adjunctive Antithrombotic Therapy to Support Reperfusion With Primary PCI*The recommended maintenance dose of aspirin to be used with ticagrelor is 81 mg daily.第8页/共47页第9页/共47页第10页/共47页第11页/共47页第12页/共47页第14页/共47页第15页/共47页第17页/共47页第18页/共47页第21页/共47页第22页/共47页第23页/共47页第24页

7、/共47页第29页/共47页第30页/共47页Renin-Angiotensin-Aldosterone Renin-Angiotensin-Aldosterone System InhibitorsSystem InhibitorsRoutine Medical Therapies第32页/共47页Renin-Angiotensin-Aldosterone System InhibitorsAn ACE inhibitor should be administered within the first 24 hours to all patients with STEMI with ante

8、rior location,HF,or EF less than or equal to 0.40,unless contraindicated.An ARB should be given to patients with STEMI who have indications for but are intolerant of ACE inhibitors.I IIa IIb IIII IIa IIb III第33页/共47页Renin-Angiotensin-Aldosterone System InhibitorsAn aldosterone antagonist should be g

9、iven to patients with STEMI and no contraindications who are already receiving an ACE inhibitor and beta blocker and who have an EF less than or equal to 0.40 and either symptomatic HF or diabetes mellitus.ACE inhibitors are reasonable for all patients with STEMI and no contraindications to their us

10、e.I IIa IIb IIII IIa IIb III第34页/共47页Renin-Angiotensin-Aldosterone SystemBIRKENHGERLANCET 2007Vasoconstriction,Oxidative Stress,Cellular Growth第35页/共47页ACEI与ARB对心血管的保护作用不同肾素肾素RPR受体受体AT2受体受体血管舒张血管舒张抗增殖抗增殖凋亡凋亡血管紧张素原血管紧张素原Ang IAng IIAT1受体受体血管收缩血管收缩细胞增殖细胞增殖基质形成基质形成醛固酮分泌醛固酮分泌血管舒张血管舒张一氧化氮一氧化氮前列腺素前列腺素EDHF无

11、活性肽无活性肽激肽原激肽原缓激肽缓激肽激肽释放酶激肽释放酶BK B2受体受体ACE ACEIACEIACEIACEI增加增加炎症因子炎症因子 PAI-1IRAP受体受体Ang AMP-A/MNEPAng(1-5)无活性肽无活性肽 Ang-(1-7)ACEAng(1-9)AT2受体受体 ACE2ACE2NEP&ACE血管舒张血管舒张抗增殖抗增殖Mas受体受体ARB廖玉华.临床心血管病杂志,2012,28(8):561-562第36页/共47页 FAMISPost Acute Myocardial InfarctionThe Fosinopril in Acute Myocardial Infar

12、ction Study(急性心肌梗死后，福辛普利的应用研究)Claudio Borghi,et al.,Am J Hypertens 1997;10:247S-254S第37页/共47页研究目的研究目的：研究在出现症状6小时内溶栓的急性前壁心肌梗塞患者早期（100 mm Hg，则逐渐加倍至目标剂量每天20mg，或安慰剂，服用3个月第39页/共47页结果1：福辛普利对左室收缩功能障碍(射血分数0.05+与安慰剂组相比，P0.05第44页/共47页FAMIS研究结论及意义早期福辛普利和溶栓联合治疗能显著减缓急性心梗患者CHF的病程，其机制与福辛普利对LV重构的影响无关第45页/共47页总结从FMC-device time及DIDO概念的提出体现2013新版ACC/AHA STEMI指南更加强调合理的再灌注治疗ACEI仍然是STEMI患者RASI抑制剂的首选（IA），是患者药物治疗的基石FAMIS研究显示溶栓联合蒙诺治疗，能显著减缓急性心梗患者CHF的病程，其机制与福辛普利对LV重构的影响无关第46页/共47页