介入医生回顾急性心梗治疗中的里程碑事件  

Interventionalists Look Back at Landmarks in AMI Therapy

（上海交通大学附属第六人民医院 杭靖宇 翻译）

关键词：

• 未来进展包括干细胞治疗、技术的改进和更为有效的药物治疗。

过去30年中的里程碑式事件改变了急性心梗的诊断和治疗。在周二进行的TCT二十周年庆的特别活动中，一些心脏介入医生回顾了这些里程碑式事件，并预测这个领域会如何发展。

PCI成为首选治疗

密执安州William Beaumont医院的心导管室主任Cindy L. Grines回忆起上世纪80年代早期和90年代直接血管成形术与溶栓药物以及相应治疗方案竞争急性心梗首选治疗方法时的情景。Grines说“我们的随机研究在上世纪90年代早期发表在《新英格兰医学杂志》上，它是最早比较直接血管成形术和溶栓治疗的临床试验。”

“所有这些研究都显示了直接血管成形术对于开通血管、减少残余狭窄和降低再梗发生率十分有效。”Grines说这些研究为随后在整个上世纪90年代进行的急性心梗直接血管成形术临床试验铺平了道路，直至直接血管成形术最终取代溶栓治疗成为治疗标准。

删除“加或减”

急性心梗治疗的另一个里程碑是减少了door-to-balloon时间。1999年的ACC/AHA 指南将目标door-to-balloon时间设定为90±30 分钟。一些介入医生依据美国各地一些医院更为出色的表现，决定进行合作以减少指南中所建议的标准door-to-balloon时间。耶鲁大学内科学教授Harlan Krumholz在发言中说“2004的治疗指南向前跨出了大胆的一步，指南决定删除‘加减30分钟’的说法”。

“常识告诉我们应当越快越好，而将目标设定为90分钟似乎是合理的。”

未来方向

哥伦比亚大学医学中心内科学教授和纽约心血管研究基金会（CRF）主席Gregg W. Stone集中介绍了正在进行中的可能对未来治疗方法产生重要影响的研究和进展。“我看到一些研究方向未来可能会获得成功，包括优化药物治疗以便改善支架术后的结果以及采用各种方法改善心肌的恢复”

Stone说“其中包括预防远端栓塞、减轻再灌注损伤、限制重构和恢复细胞功能等。”Stone说药物治疗进展包括正处于研究阶段的起效迅速的抗血小板药物cangrelor (The Medicines Company)。该药物目前正在进行3期临床试验。他认为治疗血栓的机械性方法，如血栓抽吸和去栓术等也可能对治疗结果产生影响。Stone说，另一个具有前途的领域涉及到正在进行的关于心脏修复的细胞治疗，包括胚胎、胎儿、脐血和成人始祖干细胞治疗。

（来源：www.tctmd.com）

Key Points:

• The future may include stem cell therapy, advanced technology, and more effective pharmacologic therapies.

By TCT Daily Staff

Landmark events within the past three decades have changed the landscape of AMI diagnosis and treatment.

In a special TCT 20^th Anniversary session held Tuesday, several interventional cardiologists looked back at these landmark events and gave their predictions about how the field is likely to evolve.

PCI as primary care

Cindy L. Grines, MD, director of the cardiac cath labs at William Beaumont Hospital in Royal Oak, Mich., recalled the early 1980s and 1990s when primary angioplasty was competing with thrombolytic drugs and associated protocols as the primary treatment for AMI.

"When we got our rand omized trials published in The New England Journal of Medicine in the early 1990s, they were the first randomized trials comparing primary angioplasty to thrombolytic therapy," Grines said.

"All of these trials showed that primary angioplasty was very effective at opening the vessels, reducing the residual stenosis, reducing rates of reinfarction, and the like."

The research, Grines said, paved the way for subsequent studies on primary angioplasty for AMI that continued throughout the 1990s until primary angioplasty eventually replaced thrombolysis as the standard of care.

Removing the ‘plus-or-minus’

Another landmark for AMI care was the effort to reduce door-to-balloon time. In 1999, ACC/AHA guidelines set the target door-to-balloon time at 90 min ±30 min. Citing evidence of better performance in various hospitals across the country, some interventionalists decided to work together with the goal of lowering the standard door-to-balloon time recommended in the guidelines.

"In 2004, the guidelines took a bold step forward in which the decision was made to take out the ‘plus-or-minus 30 minutes,’" Harlan Krumholz, MD, professor of internal medicine at Yale University in New Haven, Conn., said in his presentation. "There was a general sense that faster was better, and putting 90 minutes out there seemed like a reasonable goal."

The future

Gregg W. Stone, MD, professor of medicine at Columbia University Medical Center and chairman of the Cardiovascular Research Foundation in New York, highlighted ongoing research and developments that could have a major impact on treatment.

"Several initiatives I see as being potentially fruitful are under way, such as optimizing pharmacotherapy to enhance stent outcomes and enhancing myocardial recovery by a variety of methodologies," Stone said. "Some of these are preventing distal embolization, mitigating reperfusion injury, limiting remodeling and restoring cellular function."

Stone said that developments in pharmacologic therapy include the investigational rapid-acting antiplatelet agent cangrelor (The Medicines Company), currently in phase 3 trials. Mechanical approaches for treating thrombus, such as those for thrombus aspiration or thrombectomy, also could impact outcomes, he said.

Another promising area involves ongoing research into cardioreparative cell therapy, including embryonic, fetal, cord-blood, and adult progenitor stem cells, Stone said.

Disclosures:

（source：www.tctmd.com）