GW-ICC 2016:吴永健教授谈冠心病血运重建策略如何落地基层医院?

2016-10-17 佚名 《门诊》杂志

▲ 吴永健教授第二十七届长城国际心血管病会议期间,县域医疗联盟成立后第一次正式会议——县域医疗论坛召开,旨在对基层医师培训冠心病治疗相关技术和理念。一个国家现代化发展水平的高低,往往体现在医疗现代化水平。我国各地区间医疗水平发展不平衡,县级医院数量庞大又承上启下,是我国医疗体系的重要组成部分,因此提高县级医院的诊疗技术水平势在必行。本次会议期间,中国医学科学院阜外医院的吴永健教授详细阐述了冠心


▲ 吴永健教授


第二十七届长城国际心血管病会议期间,县域医疗联盟成立后第一次正式会议——县域医疗论坛召开,旨在对基层医师培训冠心病治疗相关技术和理念。一个国家现代化发展水平的高低,往往体现在医疗现代化水平。我国各地区间医疗水平发展不平衡,县级医院数量庞大又承上启下,是我国医疗体系的重要组成部分,因此提高县级医院的诊疗技术水平势在必行。本次会议期间,中国医学科学院阜外医院的吴永健教授详细阐述了冠心病血运重建策略的选择依据以及如何在基层医院开展诊治工作。


血运重建策略的发展历程


吴永健教授指出,冠心病患者血运重建的目的是为了提高患者生活质量,延长寿命。冠心病患者血运重建治疗主要有三种方式:药物治疗(溶栓治疗),介入治疗(急诊or择期PCI),外科手术(急诊or择期CABG)。目前介入治疗已经成为冠心病患者主要的治疗手段。上世纪80年代以前,我国所有的冠心病患者均实行药物治疗,但是早期诊断和药物治疗手段都比较有限。冠心病治疗在上世纪80年代末进入快速发展期,不仅药物治疗得到发展,更重要是介入以及搭桥的进步。随着介入技术的普及,溶栓治疗地位有所下降。China PEACE研究显示,我国近十年溶栓治疗从45%降到27.4%。中国PCI例数增加明显,增幅呈下降趋势,而介入治疗主要集中在大城市,在县级医院溶栓或许是更主要的治疗方法。在此基础上,加强县级医院的介入水平,选择患者最合适的治疗方案,才有可能满足日益增多心梗患者的治疗需要。


针对冠心病患者行PCI术或是CABG,临床医师通常依据两个量表进行评估:内科医师依据SYNTAX评分,外科医师依据STS风险评分,来评估不同策略的获益程度。不管是介入还是搭桥手术,均需要应用抗凝/抗血小板药物,需要根据ACS-GRACE评分和CRUSADE出血评分来评估患者出血风险。因此临床医师需要考虑到患者各方面的风险因素,评估获益程度来最终制定治疗策略。如果患者既不能行PCI也不能进行搭桥手术,药物治疗又效果不佳的情况下,则可以考虑杂交手术。


血运重建原则:不同情况下的个体化原则


目前常规血运重建治疗策略的制定存在两大方向:主观唯心主义-做想做的,遵循上级医师临床工作经验;客观唯物主义-做该做的,严格遵从指南。而在吴永健教授看来,冠心病复杂病变患者血运重建策略的选择必须根据患者的个体差异(比如女性,高龄,BMI,高血压糖尿病,高血脂,左心功能,肝肾功能不全,其他合并疾病等)以及病变的特殊性(比如左主干,分叉病变,重度钙化,长病变,迂曲病变,闭塞病变,三支病变等)来个体化制定,选择适合患者的治疗方案。


对于伴随心力衰竭和心原性休克的患者,血运重建治疗可以缓解心力衰竭患者的心绞痛症状。SHOCK研究显示,紧急血运重建治疗可以提高AMI合并心原性休克患者的存活率,需要心脏团队对患者的病情、冠脉解剖、SYNTAX评分、合并症以及血运重建治疗的预期程度进行综合准确评估。对稳定型冠心病合并糖尿病患者而言,BARI-2D研究显示与药物治疗相比较,血运重建治疗组3年随访结果显示心绞痛恶化和再次血运重建治疗的发生率更低。FRISC-2研究和TACTICS-TIMI研究显示,早期血运重建治疗优于保守治疗。一项荟萃分析显示对于糖尿病患者,CABG改善存活率优于PCI。与PCI比较,SYNTAX积分越高,CABG降低主要心血管MACCE发生率的获益程度越大。


对于慢性肾病疾病患者,血运重建治疗的临床试验大多数都未入选慢性肾脏病患者,一项观察性研究显示,接受血运重建治疗的慢性肾脏疾病合并多支血管病变的患者的存活率要优于药物治疗。重度慢性肾脏疾病合并多支血管病变的患者首选CABG,且CABG的死亡率和心梗发生率低于PCI。约有40%的瓣膜病患者合并冠状动脉疾病,准备施行瓣膜病手术的患者,均应行冠状动脉造影检查,接受主动脉瓣置换手术的患者如合并严重冠脉疾病,同时行CABG手术,然目前有关外科瓣膜置换+PCI的杂交手术报道甚少。CABG术后早期桥血管闭塞率可达12%,这种情况下应急诊行PCI治疗,以限制心肌梗死范围。PCI的靶血管可以是自体血管或入内动脉桥血管,但禁忌对急性闭塞的桥血管行PCI治疗。


杂交手术:血运重建的第四种选择


总体而言,冠心病患者血运重建策略评价需考虑以下四个方面的因素:治疗方法的安全性;手术操作简单节省时间;经济效益比;医患的认可度和接受度。


最后吴永健教授介绍了杂交手术方案,包括“一站式”杂交手术(LAD行左内乳动脉搭桥——术后即刻行LIMA评价——RCA或LCX行PCI治疗。该方案需要建立“一站式”杂交手术室,对医院外科技术要求高,患者接受程度相对较高)和“分步式”杂交手术(地方医院对RCA或LCX行PCI治疗——上级医院对LAD行左内乳动脉搭桥,不能即刻评估LIMA,可降低费用及住院时间,对地方医院要求较低,可以充分利用优质医疗)。


吴永健教授最后指出,对于县级医院的医师而言,需要充分考虑以上所讲的原则,详细了解患者的既往病史,正确评估,合理治疗。因此总结冠心病患者血运重建策略:没有最好,只有更好,只选对的,不选贵的。


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    2016-10-19 雅文博武

    学习了先进的医学知识

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    2016-10-19 zhs3884
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    2016-10-19 chenwq12
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    2016-10-17 医路开来

    谢谢分享,,

    0

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    2016-10-17 1e0ece0dm09(暂无匿称)

    谢谢分享,长见识了

    0

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