β受体阻滞剂在PCI术的应用河北医科大学第二医院常亮提纲◆β受体阻滞剂药理◆心率增快增加冠心病患者的临床事件◆β受体阻滞剂在PCI围手术期的应用药理学及作用机制•主要机制：对抗儿茶酚胺类肾上腺素能递质毒性尤其是通过β1受体介导的心脏毒性，是此类药物发挥心血管保护作用。•其他机制：•1.抗高血压作用•2.抗心肌缺血作用•3.阻断肾小球旁细胞β1受体，抑制肾素-AngII-醛固酮系统。•4.改善心脏功能增加LVEF:•5.抗心律失常作用•6.其他：抑制β肾上腺素能通路介导的心肌细胞凋亡、抑制血小板聚集、减少对粥样硬化斑块的机械应激、防止斑块破裂等。心率增快增加冠心病患者的风险！Theeffectofheartrateonlocalhaemodynamicforcesontheendothelium.Mechanismswherebyanelevatedheartrateleadstoadverseoutcomesinpatientswithcoronaryarterydisease.ImpactofLeftVentricularEjectionFractiononClinicalOutcomesOverFiveYearsAfterInfarct-RelatedCoronaryArteryRecanalization(fromtheOccludedArteryTrial[OAT])Inconclusion,optimalmedicaltherapyremainstheoveralltreatmentofchoiceforstablepatientswithapersistenttotalocclusionoftheinfarct-relatedarteryafteracutemyocardialinfarction,irrespectiveofthebaselineEF.Inpatientswithnormalormoderatelyimpairedleftventricularcontractility,PCIreducedtheneedforsubsequentrevascularizationbutdidnototherwiseimproveoutcomes.(AmJCardiol2010;105:10–16)包括美托洛尔在内的最佳药物治疗仍然是冠心病治疗的基石！β阻滞剂在急性心肌梗死的应用Setting/indicationClassLeveli.v.administrationForreliefofischaemicpainTocontrolhypertension,sinustachycardiaPrimarypreventionofsuddencardiacdeathSustainedventriculartachycardiaSupraventriculartachyarrhythmiasTolimitinfarctsizeAllpatientswithoutcontraindicationsOraladministrationAllpatientswithoutcontraindicationsIIIIIIIaIIbIBBBCCAAAβ阻滞剂在慢性稳定性心绞痛的应用Expertconsensusdocumentonβ-adrenergicreceptorblockers.EuropeanHeartJournal.2004,25:1341–1362.Setting/indicationClassLevelPreviousinfarctionToimprovesurvivalToreducereinfarctionToprevent/controlischaemiaNopreviousinfarctionToimprovesurvivalToreducereinfarctionToprevent/controlischaemiaIIIIIIAAACBAHeartRateasanIndependentPrognosticRiskFactorinPatientswithAcuteMyocardialInfarctionUndergoingPrimaryPercutaneousCoronaryInterventionCONCLUSION:InpatientswithacutemyocardialinfarctionundergoingprimaryPCI,elevatedheartrate(80bpmorgreater)identifiesthoseatincreasedriskofdeath.Itisunknownwhetherheartratereductionwillresultinimprovedoutcomeinthissettingofpatients.急性心肌梗死患者急诊行PCI，心率增快的患者发生院内死亡的风险明显增高！β阻滞剂在心肌梗塞后二级预防的应用Setting/indicationClassLevelAllpatientswithoutcontraindications,indefinitelyToimprovesurvivalTopreventreinfarctionPrimarypreventionofsuddencardiacdeathToprevent/treatlateventriculararrhythmiasIIIIIIaAAAABβ阻滞剂在非ST段抬高ACS的应用Setting/indicationClassLevelEarlybenefit,reductionofischaemiaEarlybenefit,preventionMILong-termsecondarypreventionIIIBBBPURE研究：我国社区冠心病患者的β受体阻滞剂使用率低于中低收入国家平均水平YusufS,etal.Lancet.2011;378:1231-1233.中国属于中低收入国家45.444.93712.511.96.81.901020304050北美和欧洲中东南美马来西亚南亚中国非洲冠心病患者β阻滞剂使用率%46.53111.5%11.101020304050高收入国家中高收入国家中低收入国家低收入国家冠心病患者β阻滞剂使用率%实践与指南的差距：β阻滞剂在中国冠心病患者中使用现状中华医学会心血管病学分会中华心血管病杂志编辑委员会.β肾上腺素能受体阻滞剂在心血管疾病应用专家共识.使用率低使用时间滞后剂量较低获益渐少β受体阻滞剂在PCI围手术期...
