再灌注治疗指南强调需要快速治疗

(阜外心血管病医院 高立建 翻译)

要点：欧洲心脏病学会（ESC）在慕尼黑举行的ESC年会上公布了新的STEMI治疗指南

因强调再灌注治疗，欧洲心脏病学会新的STEMI治疗指南第一次在有美国听会者参加面前公布。

来自比利时列弗大学的Franz Van de Werf博士讨论了该指南，这是最近在慕尼黑举行的ESC年会上第一次公布的指南，是对2003版指南的更新。

根据Franz Van de Werf博士的发言，新指南与2003版指南的主要区别包括院前治疗及救治网络，直接PCI与溶栓治疗选择标准，抗血小板的联合治疗，未进行直接PCI患者的造影和二级预防。

胸痛持续到12小时

再灌注治疗目前建议应用于所有的胸痛和/或胸部不适持续到12个小时，并且持续性ST段抬高或新出现的左束支传导阻滞。Van de Werf说道：如果症状在12小时后开始出现，当有临床和/或ECG证据表明有正在发生的缺血，对于稳定的、发病后超过12-24小时就诊的患者，也建议行再灌注治疗。发病超过24小时没有缺血症状的稳定患者，建议行PCI治疗开通梗死相关动脉。

直接PCI进行再灌注治疗建议也进行了更新。Van de Werf说道：如果再灌注治疗由一个有经验的团队在患者首诊后尽可能短的时间内完成，PCI应作为首选方法。首诊-球囊时间在任何情况下都应当小于2小时和/或早就诊的大面积梗死、出血风险低的患者不到90分钟。

PCI也适用于休克和有溶栓禁忌症的患者，不考虑是否有时间上的耽误。对大面积心肌梗死患者溶栓失败后12小时内应考虑进行补救性PCI。

ACC/AHA指南

Alice Jacobs医生，来自于波士顿医学中心，是刚刚离任的AHA主席，在周一的基本策略报告中陈述了ACC/AHA关于再灌注治疗指南。美国指南自从1990年开始制定以来，已经修订了几版，最新版本是2007年制定的。

根据Jacobs医生的发言，2007版STEMI患者治疗指南建议，初诊患者到具备完成PCI能力的医院就诊，应当在发病90分钟内完成直接PCI治疗。这是对2004版本指南的更新，2004版本中强调直接PCI应当尽可能快的完成以达到就诊-球囊或门-球囊时间在90分钟以内的目标。

患者就诊于不具备完成PCI治疗的医院，并且不能在初诊后90分钟内转移到具备PCI治疗的医院进行PCI治疗，应当在到医院就诊30分钟内进行溶栓治疗，除非有溶栓禁忌症。这也是对2004版指南的更新，2004版指南中强调患者就诊于不具备完成PCI治疗的医院，并且不能在初诊后90分钟内转移到具备PCI治疗医院进行PCI治疗，除非有禁忌症，均应当进行溶栓治疗。

指南鼓励患者采用完善、快速的急救医疗服务处（EMS）交通系统，不鼓励自驾车到医疗机构，应当优先考虑减少门-球囊时间。

Jacobs说ACC/AHA指南的目标是：在所有参加的医院，达到至少75%的非转运STEMI患者直接PCI的门-球囊时间在90分钟以内。

研究已经证明了PCI-相关时间延迟与死亡率直接相关。Jacobs 说道：“PCI每延迟10分钟，死亡率的差异会减少1%”

（来源：www.tctmd.com）

Reperfusion Therapy Guidelines Stress Need for Prompt Treatment  

Key Points:

• European Society of Cardiology unveiled new guidelines for STEMI management at recent ESC meeting in Munich.

By TCT Daily Staff

With an emphasis on reperfusion therapy, the new European Society of Cardiology guidelines for the management of STEMI were presented for the first time in front of a U.S. audience.

Franz Van de Werf, MD, PhD, from the University of Leuven in Belgium, discussed the guidelines, which were first unveiled at the recent ESC meeting in Munich and are an update of the 2003 version.

According to Van de Werf, the main differences with the 2003 guidelines involve prehospital management and networks, selection criteria for primary PCI vs. fibrinolytic therapy, antithrombotic co-therapies, angiography in patients not undergoing primary PCI, and secondary prevention.

Chest pain up to 12 hours

Reperfusion therapy is now recommended for all patients with chest pain and/or discomfort lasting up to 12 hours and with persistent ST-segment elevation or new left bundle branch block. It should be considered when there is clinical and/or ECG evidence of ongoing ischemia if symptoms began more than 12 hours before, Van de Werf said.

Reperfusion therapy also is recommended for stable patients presenting more than 12 to 24 hours after symptom onset. PCI of a totally occluded infarct artery is recommended for stable patients without signs of ischemia more than 24 hours after symptom onset.

The recommendation involving reperfusion therapy for primary PCI also has also been updated. Van de Werf said PCI should be considered the preferred reperfusion treatment if performed by an experienced team as soon as possible after first medical contact. Time from first medical contact to balloon should be less than two hours in any case and/or less than 90 minutes in patients presenting early and with large infarct and low risk of bleeding.

PCI also is indicated for patients in shock and those with contraindications to fibrinolytic therapy, irrespective of time delay. Rescue PCI should be considered after failed fibrinolysis in patients with large infarcts if performed within 12 hours.

ACC/AHA guidelines

Alice Jacobs, MD, a recent past president of the AHA who is from Boston Medical Center, presented the American College of Cardiology/American Heart Association guidelines regarding reperfusion therapy during her keynote address on Monday. The U.S. guidelines were updated in 2007 and have evolved through several versions since they were originally published in 1990.

According to Jacobs, the 2007 ACC/AHA guidelines recommend that STEMI patients presenting to a hospital with PCI capability should be treated with primary PCI within 90 minutes of first medical contact. This is an update of the 2004 guidelines, which stated that primary PCI should be performed as quickly as possible with the goal of a medical contact-to-balloon or door-to-balloon interval of within 90 minutes.

Patients with STEMI presenting to a hospital without PCI capability who cannot be transferred and undergo PCI within 90 minutes of first medical contact should be treated with fibrinolytic therapy within 30 minutes of hospital presentation as a systems goal, unless fibrinolytic therapy is contraindicated. This, also, is an update of the 2004 guidelines, which stated that STEMI patients presenting to a facility without the capability for expert primary PCI within 90 minutes of first medical system contact should undergo fibrinolytic therapy unless contraindicated.

The guidelines also discourage patient self-transport to medical facilities and encourage improved and faster EMS transport. Reducing door-to-balloon time should be a priority, they state.

Jacobs said the ACC/AHA guidelines goal is to achieve a door-to-balloon time of within 90 minutes for at least 75% of nontransfer primary PCI patients with STEMI in all participating hospitals performing primary PCI.

Research has demonstrated a direct relationship between PCI-related time delay and mortality. "For every 10-minute delay to PCI, there is a 1% reduction in mortality difference," Jacobs said.