Медикаменты,ангиопластика, хирургия:как найти баланс Беленький Дмитрий Ильич

Проблемы Стабильная стенокардия Стабильная стенокардия ОКС без элевации ST ОКС без элевации ST ОКС с элевацией ST ОКС с элевацией ST

Первичная ангиопластика в сравнении с тромболизисом

Mortality rates with primary PCI as a function of PCI-related time delay P = PCI-Related Time Delay (door-to-balloon - door toneedle) Absolute Risk Difference in Death (%) Circle sizes =sample size of the individual study. Solid line=weighted meta- regression. Nallamothu BK, Bates ER. Am J Cardiol. 2003;92: min Benefit Favors PCI Harm Favors Lysis For Every 10 min delay to PCI: 1% reduction in mortality difference towards lytics

Door to Balloon Times Among Patients Transferred in NRMI 4 Door to Data: 50 th : 9 Min. 25 th : 4 Min. 75 th : 16 Min. Data to Cath Lab Arrival: 50 th : 132 Min. 25 th : 88 Min. 75 th : 219 Min. Cath Lab to Balloon: 50 th : 37 Min. 25 th : 28 Min 75 th : 50 Min Total Door 1 to Balloon Time: 185 minutes (25 th : 137; 75 th : 276) Percent of Patients with Door to Balloon Time < 90 Min.: 3.0% Sample Size: 1,346; Time Period: January 2002 – December 2002 Accessed on August 6, guidelines/stemi/index.pdf. pg.61

CAPTIM Comparison of Angioplasty and Prehospital Thrombolysis in Acute Myocardial Infarction Primary Composite Endpoint- Death, Reinfarction, Disabling Stroke Bonnefoy E, et al. Lancet 2002;360:825-9

CAPTIM -1Year Results Sx to Treatment Analysis Touboul P. Presented at: The 18th International Symposium on Thrombolysis and Interventional Therapy in Acute Myocardial Infarction - George Washington University Symposium; November 16, 2002; Chicago, Ill. Sx 2 h 0.0 Death Sx 2 h Pre-hospital Lysis Primary PCI Death P= Pre-hospital Lysis Primary PCI Death P= Percent

Материалы МУЗ МКБ СМП 2 за 2005 г ОИМ n-691 КШ n-82(12%) Умерло n- 39(53%)

Зависимость летальности от возраста % 23.2%

Эффективность тромболизиса в зависимости от возраста

Увеличение летальности у больных РЕ-ИМ ОИМn-478РЕ-ИМn-23P Летальность11,8%26,1%0,02

Кривые Каплана-Мейера выживаемости больных Ре-ИМ

Summary: Selection of the Optimal Reperfusion Options for the STEMI Patient: 2004 Full Dose Fibrinolytic Monotherapy Door to balloon (D- B) > 90 min Door to balloon (D- B) > 90 min Lack of access to skilled PCI center Lack of access to skilled PCI center (D-B) – (D-N) > 1 h (D-B) – (D-N) > 1 h < 3 h from symptom onset < 3 h from symptom onset Full Dose Fibrinolytic Monotherapy Door to balloon (D- B) > 90 min Door to balloon (D- B) > 90 min Lack of access to skilled PCI center Lack of access to skilled PCI center (D-B) – (D-N) > 1 h (D-B) – (D-N) > 1 h < 3 h from symptom onset < 3 h from symptom onset Invasive Strategy Cardiogenic shock (age < 75) Cardiogenic shock (age < 75) Bleeding risk Bleeding risk Diagnosis in doubt (pericarditis/aneurysm) Diagnosis in doubt (pericarditis/aneurysm) Door to balloon < 90 min Door to balloon < 90 min Skilled PCI center available, defined by: Skilled PCI center available, defined by: Operator experience > 75 cases/yrOperator experience > 75 cases/yr Team experience > 36 primary PCI/yrTeam experience > 36 primary PCI/yr Age > 75 Age > 75 Symptoms > 2-3 h Symptoms > 2-3 h Invasive Strategy Cardiogenic shock (age < 75) Cardiogenic shock (age < 75) Bleeding risk Bleeding risk Diagnosis in doubt (pericarditis/aneurysm) Diagnosis in doubt (pericarditis/aneurysm) Door to balloon < 90 min Door to balloon < 90 min Skilled PCI center available, defined by: Skilled PCI center available, defined by: Operator experience > 75 cases/yrOperator experience > 75 cases/yr Team experience > 36 primary PCI/yrTeam experience > 36 primary PCI/yr Age > 75 Age > 75 Symptoms > 2-3 h Symptoms > 2-3 h