Reperfusion Strategies in Acute Coronary Syndromes
Reperfusion Strategies in Acute Coronary Syndromes
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DOI：
10.1161/circresaha.114.302744
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发表时间：
2014-06-06
影响因子：
20.1
通讯作者：
Granger, Christopher B.
中科院分区：
文献类型：
--
作者：
Bagai, Akshay;Dangas, George D.;Granger, Christopher B.
适当的血管造影时机以促进血运重建对于ST段抬高心肌梗死和非ST段抬高急性冠状动脉综合征患者的结局优化至关重要。在ST段抬高型心肌梗死中及时再灌注梗死相关冠状动脉，无论是纤溶还是经皮冠状动脉介入治疗，都能最大限度地减少心肌损伤，缩小梗死面积，降低发病率和死亡率。如果能够及时进行，直接经皮冠状动脉介入治疗是首选的再灌注方法。减少与医疗系统相关的再灌注延迟的策略包括ST段抬高心肌梗死护理的区域化、进行院前ECG检查、院前激活导管室、绕过地理位置较近的不具备经皮冠状动脉介入能力的医院、绕过具备经皮冠状动脉介入能力的医院急诊科以及导管室团队的早期和持续可用性。随着这些战略的实施，流程措施，包括送货上门到气球的时间，有了很大的改善。然而，尽管门到球囊时间减少，但在过去几年中住院死亡率几乎没有变化，这表明必须解决其他因素，包括患者相关延迟，组织水平灌注的优化和心脏保护，以进一步改善患者结局。在非ST段抬高急性冠状动脉综合征患者中，早期血管造影后适当时进行血运重建也可降低死亡、MI和复发性缺血的发生率，在风险最高的患者中获益最大。在非ST段抬高急性冠状动脉综合征伴多支血管病变的患者中，血运重建方式的选择应与稳定性冠状动脉疾病相同，目标是完全缺血性血运重建。
The appropriate timing of angiography to facilitate revascularization is essential to optimize outcomes in patents with ST-segment-elevation myocardial infarction and non-ST-segment-elevation acute coronary syndromes. Timely reperfusion of the infarct-related coronary artery in ST-segment-elevation myocardial infarction both with fibrinolysis or percutaneous coronary intervention minimizes myocardial damage, reduces infarct size, and decreases morbidity and mortality. Primary percutaneous coronary intervention is the preferred reperfusion method if it can be performed in a timely manner. Strategies to reduce health system-related delays in reperfusion include regionalization of ST-segment-elevation myocardial infarction care, performing prehospital ECGs, prehospital activation of the catheterization laboratory, bypassing geographically closer nonpercutaneous coronary intervention-capable hospitals, bypassing the percutaneous coronary intervention-capable hospital emergency department, and early and consistent availability of the catheterization laboratory team. With implementation of such strategies, there has been significant improvement in process measures, including door-to-balloon time. However, despite reductions in door-to-balloon times, there has been little change during the past several years in in-hospital mortality, suggesting additional factors including patient-related delays, optimization of tissue-level perfusion, and cardioprotection must be addressed to improve patient outcomes further. Early angiography followed by revascularization when appropriate also reduces rates of death, MI, and recurrent ischemia in patients with non-ST-segment-elevation acute coronary syndromes, with the greatest benefits realized in the highest risk patients. Among patients with non-ST-segment-elevation acute coronary syndromes with multivessel disease, choice of revascularization modality should be made as in stable coronary artery disease, with a goal of complete ischemic revascularization.