1、ACEI在在2013版版ACC/AHA STEMI指南中的地位指南中的地位整理課件主要內容主要內容 2013版ACC/AHA STEMI指南主要變化 ACEI在ACC/AHA STEMI指南中的基石地位 FAMIS：第三代ACEI蒙諾在急性心梗中的研究整理課件2013 ACCF/AHA Guideline for the Management of ST-Elevation Myocardial InfarctionDeveloped in Collaboration with American College of Emergency Physicians and Society for C

2、ardiovascular Angiography and Interventions American College of Cardiology Foundation and American Heart Association, Inc.2013 ACCF/AHA Guideline for the Management of ST-Elevation Myocardial Infarction (Journal of the American College of Cardiology). Published on December 17, 2012整理課件Reperfusion Th

3、erapy for Patients with STEMI*Patients with cardiogenic shock or severe heart failure initially seen at a nonPCI-capable hospital should be transferred for cardiac catheterization and revascularization as soon as possible, irrespective of time delay from MI onset (Class I, LOE: B). Angiography and r

4、evascularization should not be performed within the first 2 to 3 hours after administration of fibrinolytic therapy.整理課件Regional Systems of STEMI Care, Reperfusion Therapy, and Time-to-Treatment Goals All communities should create and maintain a regional system of STEMI care that includes assessment

5、 and continuous quality improvement of EMS and hospital-based activities. Performance can be facilitated by participating in programs such as Mission: Lifeline and the D2B Alliance. I IIa IIb IIIPerformance of a 12-lead ECG by EMS personnel at the site of FMC is recommended in patients with symptoms

6、 consistent with STEMI. I IIa IIb III整理課件整理課件Primary PCI in STEMI整理課件整理課件Adjunctive Antithrombotic Therapy to Support Reperfusion With Primary PCI*The recommended maintenance dose of aspirin to be used with ticagrelor is 81 mg daily.整理課件整理課件整理課件整理課件整理課件整理課件整理課件整理課件整理課件整理課件整理課件整理課件整理課件整理課件整理課件整理課件整理課

7、件整理課件整理課件整理課件整理課件整理課件整理課件整理課件Renin-Angiotensin-Aldosterone Renin-Angiotensin-Aldosterone System InhibitorsSystem InhibitorsRoutine Medical Therapies整理課件Renin-Angiotensin-Aldosterone System InhibitorsAn ACE inhibitor should be administered within the first 24 hours to all patients with STEMI with ant

8、erior location, HF, or EF less than or equal to 0.40, unless contraindicated. An ARB should be given to patients with STEMI who have indications for but are intolerant of ACE inhibitors. I IIa IIb IIII IIa IIb III整理課件Renin-Angiotensin-Aldosterone System InhibitorsAn aldosterone antagonist should be

9、given to patients with STEMI and no contraindications who are already receiving an ACE inhibitor and beta blocker and who have an EF less than or equal to 0.40 and either symptomatic HF or diabetes mellitus. ACE inhibitors are reasonable for all patients with STEMI and no contraindications to their

10、use. I IIa IIb IIII IIa IIb III整理課件Renin-Angiotensin-Aldosterone SystemBIRKENHGERLANCET 2007Vasoconstriction, Oxidative Stress, Cellular Growth整理課件ACEI與與ARB對心血管的保護作用不同對心血管的保護作用不同腎素腎素RPR受體受體AT2受體受體血管舒張血管舒張抗增殖抗增殖凋亡凋亡血管緊張素原血管緊張素原Ang IAng IIAT1受體受體血管收縮血管收縮細胞增殖細胞增殖基質形成基質形成醛固酮分泌醛固酮分泌血管舒張血管舒張一氧化氮一氧化氮前列腺素前列

11、腺素EDHF無活性肽無活性肽激肽原激肽原緩激肽緩激肽激肽釋放酶激肽釋放酶BK B2受體受體ACE ACEIACEIACEIACEI增加增加炎癥因子炎癥因子 PAI-1IRAP受體受體Ang AMP-A/MNEPAng(1-5)無活性肽無活性肽 Ang-(1-7)ACEAng(1-9) AT2受體受體 ACE2ACE2NEP& ACE血管舒張血管舒張抗增殖抗增殖Mas受體受體ARB廖玉華. 臨床心血管病雜志, 2012, 28(8):561-562整理課件 FAMISPost Acute Myocardial InfarctionThe Fosinopril in Acute Myoca

12、rdial Infarction Study(急性心肌梗死后，福辛普利的應用研究)Claudio Borghi, et al., Am J Hypertens 1997; 10: 247S-254S整理課件研究目的研究目的：研究在出現癥狀6小時內溶栓的急性前壁心肌梗塞患者早期（ 100 mm Hg，則逐漸加倍至目標劑量每天20mg，或安慰劑，服用3個月整理課件結果1：福辛普利對左室收縮功能障礙 (射血分數45%)患者的影響福辛普利治療相對于安慰劑組顯著預防了左心室擴張整理課件結果2：2年內心力衰竭和死亡的累積發生率14.137.351.526.814.530.54517.50102030405

13、060總死亡總死亡CHF死亡死亡+CHF死亡死亡+NYHA -發生率（發生率（%）安慰劑安慰劑福辛普利福辛普利RR = 34.7%P = 0.04整理課件結果3：入院時沒有CHF癥狀患者2年內死亡和CHF的累積發生率14.226.847.812.817.533.905101520253035404550總死亡總死亡CHF死亡死亡+CHF發生率（發生率（%）安慰劑安慰劑福辛普利福辛普利RR = 34.1%P = 0.05RR = 29.1%P = 0.04整理課件結果4:無左室功能障礙(射血分數40%) 患者2年內死亡和CHF的發生率8.618.410.86.414.626.215.510.60

14、51015202530死亡死亡+嚴重嚴重CHF死亡死亡+CHFCHF總死亡總死亡病人百分數病人百分數（%）安慰劑安慰劑福辛普利福辛普利RR = 37.8%P = 0.070RR = 28.1%P = 0.081RR = 31.9%P = 0.059RR = 43.0%P = 0.041整理課件結果5：安全性和耐受性不良反應發生率* 病人數 (%)不良反應類型安慰劑組蒙諾組n=134n=131咳嗽7(5.2) 8(6.1)+皮疹3(2.2) 0+實驗室檢查異常94(70.1) 106(80.9) +血肌酐升高8(6.0) 11(8.4) +血鉀升高5(3.7) 6(4.6) +*不良反應的總發生率在兩組沒有顯著性差異，+與安慰劑組相比， 整理課件FAMIS研