bare- metal stents determined 1992 SAVE 1985 TIMI 1 1962 First beta- blocker developed (Black) 1980 First implantable cardioverter-defibrillator developed (Mirowski) 1969 First descript[r]
(1)PGS.TS.BS Phạm Mạnh Hùng
Viện trưởng – Viện Tim Mạch Việt Nam
Tái thông
Động Mạch Vành
(2)(3)Can thiệp ĐMV đầu (Primary PCI) ở BN NMCT cấp trên
BN nam 49 tuổi NMCT cấp, can thiệp thứ 6
(4)(5)Tỷ lệ tử vong bệnh lý tim mạch giảm đáng kể với phát triển KHKT
Nabel EG and Braunwald E NEJM 2012;366:54-63
Year
D
ea
th
s
p
er
1
00
,0
00
p
o
p
u
la
ti
o
n 600 500 400 300 200 100 0
(6)Nabel EG and Braunwald E NEJM 2012;366:54-63 Year D ea th s p er 1 00 ,0 00 p o p u la ti o n 600 500 400 300 200 100 0
1950 1960 1970 1980 1990 2000 2010 2020
1954 First Open-heart procedure (Gibbon) 1961 Coronary care unit developed (Julian) 1972 NHBPEP 1993 Superiority of primary PCI vs fibrinolysis in acute MI noted 1985 NCEP 1983 CASS 1979 Coronary angioplasty developed (Grüntzig) 1986 GISSI and ISIS-2 2002 ALLHAT 2009 Deep gene sequencing for responsiveness to cardiovascular drugs performed 2009 Genome wide association in early-onset MI described 2009 Left-ventricular assist device as destination therapy
in advanced heart failure shown to be effective 2007 Benefit of cardiac resyn-chronization therapy in heart failure demonstrated 2002 Efficacy of drug-eluting vs bare-metal stents determined 1992 SAVE 1985 TIMI 1962 First beta-blocker developed (Black) 1980 First implantable cardioverter-defibrillator developed (Mirowski) 1969 First description of CABG (Favaloro) 1976 First HMG CoA reductase inhibitor described (Endo) 1961 Risk factors defined 1958 Coronary arteriography Developed (Sones)
(7)Nabel EG and Braunwald E NEJM 2012;366:54-63 Year D ea th s p er 1 00 ,0 00 p o p u la ti o n 600 500 400 300 200 100 0
1950 1960 1970 1980 1990 2000 2010 2020
1954 First Open-heart procedure (Gibbon) 1961 Coronary care unit developed (Julian) 1972 NHBPEP 1993 Superiority of primary PCI vs fibrinolysis in acute MI noted 1985 NCEP 1983 CASS 1979 Coronary angioplasty developed (Grüntzig) 1986 GISSI and ISIS-2 2002 ALLHAT 2007 Benefit of cardiac resyn-chronization therapy in heart failure demonstrated 2002 Efficacy of drug-eluting vs bare-metal stents determined 1992 SAVE 1985 TIMI 1962 First beta-blocker developed (Black) 1980 First implantable cardioverter-defibrillator developed (Mirowski) 1969 First description of CABG (Favaloro) 1976 First HMG CoA reductase inhibitor described (Endo) 1961 Risk factors defined 1958 Coronary arteriography Developed (Sones) 2009 Deep gene sequencing for responsiveness to cardiovascular drugs performed 2009 Genome wide association in early-onset MI described 2009 Left-ventricular assist device as destination therapy
in advanced heart failure shown to be effective
(8)NMCT cấp: Sinh lý bệnh học hiểu rõ
(9)Điều trị huyết khối tắc ĐMV:
Cuộc chiến tái thông ĐMV
(10)Thuốc tiêu huyết khối ?
Did save lives compared to placebo, BUT
2 hours after t-PA
6 hours after t-PA
+
ICH
0.5-1.0% of pts
- At best, restored TIMI flow in 55% (rt-PA), +
(11)“PTCA without ICSK was performed in pts with total occlusions and pts with STO.”
“Repeat cath at 12 days showed patency of all dilated segments…”
“At follow-up of mo no AMIs have
occurred, 13 pts are asymptomatic and pts are Class II”
Báo cáo can thiệp (nong) ĐMV
(12)Grines CL et al NEJM 1993;328:673-9
Nghiên cứu PAMI (Primary Angioplasty in Myocardial Infarction) tiên
phong can thiệp ĐMV BN NMCT cấp có ST chênh lên
395 pts of any age with AMI <12 duration were prospectively randomized at 12 international centers to primary PTCA vs a 100 mg t-PA infusion: 93% TIMI-3 flow with PPCI!
P=0.06 P=0.02
p=0.05 P=0.06
Death Reinfarction
Death or reinfarction
(13)P<0.0001
P<0.0001 p=0.0002
N = 7,739
Keeley, Grines Lancet 2003;361:13-20
Từ PAMI đến 23 N/C ngẫu nhiên (RCT) so sánh PCI với Tiêu sợi huyết
p=0.0002
Death Reinfarction Hemorrhagic
stroke
(14)P<0.0001
P<0.0001 p=0.0002
N = 7,739
Keeley, Grines Lancet 2003;361:13-20
Từ PAMI đến 23 N/C ngẫu nhiên (RCT) so sánh PCI với Tiêu sợi huyết
p=0.0002
Death Reinfarction Hemorrhagic
stroke
Total stroke
Can thiệp ĐMV qua da đầu trở thành lựa
chọn ưu tiên hàng đầu
trong tái tưới máu bệnh nhân NMCT cấp có ST
(15)Các yếu tố có liên quan đến tiên lượng BN sau tháng
theo dõi (GRACE Registry): N=1,716 Cases and 3,432
Controls
Chew DP et al Heart 2010;96:1201-6
AF = attributable fraction (risk)
Note: 37.2% STEMI; Similar effect in STEMI and NSTEMI
Guideline recommendation* AF (%) 95% CI (%) Revascularization 31.9 19.4 to 42.4 Thienopyridine 10.9 2.3 to 9.8 Statin therapy 9.7 4.1 to 15.0 Rehabilitation referral 10.6 -2.4 to 21.5 ACE inhibitor 4.3 -0.1 to 9.4 Glycoprotein IIb/IIIa inhibition 1.9 -1.68 to 17.3 ß-blocker 0.1 -2.8 to 4.6
1.50
1.25
1.00
0.75
0.50
0.25
0
None Revasc. + Statin + Thienopyridine+ GP IIa/IIIa + Rehab + ACE I + ASA
1.00
0.58
0.44
0.36 0.35 0.33
0.29
0.25 0.29
+ ß-blocker
R
e
la
ti
ve
S
u
rv
iv
a
(16)0 20 40 60 80 100
1 3 6 12 24
Extent of salvage (% of area at risk)
Treatment objectives
Time to treatment is critical
Opening the IRA (PCI > lysis)
Hours
Liên quan thời gian tái thông, vùng tim sống tiên lượng
Gersh, Stone, Holmes JAMA 2005
Median U.S Sx-ER: 2°
M
o
rt
a
lit
y
re
d
u
ct
io
n
(
%
)
60’ DBT
Symptom to balloon: 3.0°
Modifying factors
• Collaterals • Ischemic
(17)Thời gian từ lúc có triệu chứng đến thơng ĐMV có liên quan đến tiên lượng sau năm PCI
BN NMCT cấp
The relative risk of 1-year mortality increases by 7.5% for each 30-minute delay
De Luca et al Circulation 2004;109:1223-1225
12 10 8 6 4 2 0
Ischemic Time (minutes)
1
-y
e
a
r
M
o
rt
a
lit
y
(
%
)
Y=2.86 (± 1.46) + 0.0045X1 + 0.000043X2
P<0.001
(18)Do vậy, làm để làm giảm thời gian từ lúc BN có triệu
chứng đến lúc can thiệp ĐMV
Tăng cường nhận thức cộng đồng
Thành lập đơn vị/khu giường cấp cứu đau thắt ngực
tại khoa cấp cứu BV Điều phối vùng
Điện tâm đồ từ xa
Liên hệ sớm - Khởi động đơn vị TMCT từ trước nhập viện
(19)Kinh nghiệm nước phát triển (NRMI):
774,279 reperfusion eligible STEMI pts at 2,157 hospitals from 1990-2006
Gibson CM et al Am Heart J 2008;156:1035-44
Reductions in DBT and In-hospital Mortality
MV analysis: 5.8% of the reduction in mortality was explained by ↓DBT
D B T ( m in s) 137 87 79 111 226 120 M o rt al it y (% ) 3.9% 3.3% 3.1% 8.6% 8.7% 8.6%
All Ptrend <0.001
All Ptrend <0.001
All patients Transfers Non-transfers
1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 1994 10 6 5 4 2 0 3 9 1 8 7 All patients Transfers Non-transfers
(20)