老年冠心病围术期多联抗血小板治疗策略和经验.pptx

单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,#,单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,#,点击此处编辑副文本格式,2,二级,2,三级,3,四级,4,五级,5,#,点击此处编辑主文本格式,2,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,Click to edit Master title style,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,#,单击此处编辑母版标题样式,#,老年冠心病围术期多联抗血小板治疗策略和经验,北京协和医院心内科 严晓伟,一、二级预防性治疗,阿斯匹林？,抗血小板治疗是可以贯穿动脉硬化的全过程,从,30,岁开始,年龄与抗血小板治疗,ISIS-2,研究，,17178,例,AMI,后患者。,Lancet 11:349,1988,联合抗栓治疗老年患者获益更大,PRISM-PLUS,PCI,后斑块撕裂是血小板激活的基础,血小板活化,血小板膜,纤维蛋白原,GPIIb/IIIa,受体,GPIIb/IIIa,受体抑制剂,血小板,噻氯匹定,肾上腺素,胶原蛋白,凝血酶,阿司匹林,ADP,阿司匹林,+,氯吡格雷使,ACS,PCI,患者获益增加,试验 人群,n,时间,RR,CURE ACS without STEMI 12562 3-12m 0.80(0.72-0.9),PCI-CURE PCI+CURE 2658 9m 0.7(0.5-0.97),CLARITY STEMI 3491 30d 0.8(0.65-0.97),COMMIT Acute MI 45852 up to 4w 0.91(0.86-0.97),1,0.5,利于双重,抗血小板,利于单一,抗血小板,CURE,研究,CP999547-2,Yusuf S et al NEJM 2001;16:494-502,非,ST,段抬高,ACS,12,562,例,阿司匹林,75-325 mg qd,+,安慰剂,(n=6,303),随访,3-12,月,(,平均,9,月,),阿司匹林,+,氯吡格雷,300 mg load,75 mg qd,(n=6,259),CURE,研究,:,心血管死亡,/,MI,/,卒中的发生率,1,年,CP999731-3,Clopidogrel(n=6,303),Placebo(n=6,259),P=0.00003,研究登记后天数,心血管死亡,/,MI,/,卒中发生率,%,CURE,研究,事件发生率,(%),RR 0.80,P=0.00005,CP995058-6,心血管死亡,/,MI/,卒中,氯吡格雷,(n=6,259),安慰剂,(n=6,303),阿司匹林,+,心血管死亡,MI,卒中,非心血管死亡,RR 0.92,P=NS,RR 0.77,P0.05,主要终点,45,（,4.17,）,43,（,3.98,）,0.82,严重出血,12,（,1.11,）,8,（,0.74,）,0.37,血小板减少症,10,（,9.26,）,0,（,0,）,0.002,Kastrati A,，,NEJM,2004,350:232-238,三联抗血小板治疗,30,天的累积主要终点事件发生率：死亡、心肌梗死和靶血管血运重建。,Kastrati A,，,NEJM,2004,350:232-238,研究的外延性,该研究排除标准：,胰岛素依赖性糖尿病,具有出血素质者,严重、未控制的高血压患者,(SBP180),血小板计数低于,10,万或高于,60,万,/,立方毫米,血红蛋白低于,10g/dl,Kastrati A,，,NEJM,2004,350:232-238,CHARISMA,多种危险因素亚组,氯吡格雷阿司匹林组,阿司匹林组,%,2,0,6,4,全因死亡率,心血管死亡率,5.4,3.8,3.9,2.2,P=0.04,P=0.01,严重出血率,2.0,1.2,P=0.07,中度出血率,2.2,1.4,P=0.08,（,n=3284,）,CHARISMA,亚组分析,症状性亚组：加氯吡格雷组事件下降的同时,中度出血率显著增高,（）,2,0,6,4,终点事件,6.9,7.9,P=0.046,氯吡格雷,ASA,ASA,严重出血率,1.6,1.4,P=0.39,中度出血率,2.1,1.3,P0.001,有症状亚组：入选时即有确诊的心脑血管疾病患者,并符合特定入组条件者，,n=12153,8,氯吡格雷加阿司匹林与单用阿司匹林预防动脉粥样硬化事件（,CHARISMA,）,Bhatt DL,et al,NEJM 2006;354:1706,0,1,2,3,4,5,6,7,8,9,阿司匹林,阿司匹林加氯吡格雷,总体,多个危险因素患者,有症状动脉粥样硬化疾病患者,心血管死亡、,MI,、卒中,GUSTO,中度或重度出血,CABG,术前抗血小板,Richard H.Hongo,JACC,2002;40;231-237,N=224,平均年龄,67,岁,CABG,术前抗血小板,Richard H.Hongo,JACC,2002;40;231-237,N=224,平均年龄,67,岁,老年患者出院时处方率较低,（在无禁忌症的患者中）,100%,90%,80%,70%,60%,50%,40%,30%,20%,50,60,70,80,90,年龄（年）,比例,阿司匹林,-,受体阻滞药,降脂药物,ACE,抑制剂,氯吡格雷,75mg,Alexander KA,J Am coll Cardiol 2005;46:1479-87,对,PCI,围手术期,ASA,的推荐,ACC/AHA PCI,指南,2007,ASA 162 mg-325mg/d,BMS,支架后至少服用,1,个月；,SES,支架后至少服用,3,个月；,PES,支架后至少服用,6,个月。,此后,75 mg,162 mg/d,终身服用。,对易于发生出血的患者，可以采用低剂量阿司匹林治疗,75 mg-162 mg/d,氯吡格雷,75mg/d,BMS,支架后至少服用,1,个月（出血高危患者服用,2,周）,SES,和,PES,支架后所有患者至少服用,12,个月；,对明显出血倾向的患者，,FDA,认可的使用时间为,SES-3,个月，,PES 6,个月,1,年以后继续治疗的理想疗程尚不明确，需要根据患者 风险,/,获益综合考虑,对,PCI,围手术期,ASA,的推荐,ACC/AHA PCI,指南,2007,告知患者术后将采用双重抗血小板治疗（,DAT,）及其风险,如果患者不愿意和不能够采用足够长时间的双重抗血小板治疗，应采取其他的治疗方法,为减少,DAT,所致出血的发生率，可以采用小剂量阿司匹林,(75 mg,162 mg/d),长期治疗,择期手术应推迟至,1,年以后；对无法推迟的手术，在接受,DES,的高危患者，围手术期应考虑采用阿司匹林治疗,对,PCI,围手术期双重抗血小板治疗的推荐,ACC/AHA PCI,指南,2007,老老年患者的多重抗血小板治疗,北京协和医院,47,名,80,岁以上的专家中，因服用联合抗血小板药物,(,阿司匹林,:75100 mg/d,氯吡格雷,75 mg/d,未用负荷剂量,),而导致中、大出血、危及生命或需住院、输血,/,输血小板的病例共,8,例,提示,老老年患者的双重抗血小板治疗所致严重出血的比例远远超过,1.8%(,阿司匹林,),和,2.1%(,两药联用,),。,纪宝华，中国医学论坛报,不同种族患者的差别,将国外中老年人群的用药剂量用至国人老年患者存在一定的不确定性,临床研究均排除,80,岁以上的老年,且不同种族的体重差异较大。,对老年高危患者抗血小板或抗凝治疗者应密切监护,适当减低用药剂量：较低剂量的阿司匹林和氯吡格雷，酌情给予负荷剂量，,80,岁以上人群采用联合抗血小板、抗凝治疗应该慎重。,纪宝华，中国医学论坛报,针对老老年患者尚未解决的问题,从治疗的风险,/,效益来说,单药治疗还是联合治疗更为理想,?,联合用药的剂量应该是多少,?,围手术期是否应该采用负荷剂量，负荷剂量应该是多少,?,对那些患者应该避免使用,DES?,对老年围手术期患者应该考虑的一些问题,对接受,PCI,的老年,/,老老年患者，术前应慎重考虑术后双重抗血小板治疗的可能性,临床研究并没有阐明多重抗血小板治疗在这些患者的安全性，应评估患者的出血倾向,对不能坚持双重抗血小板治疗,1,年的患者，尽量不采用药物洗脱支架,(DES),考虑老年人的合并用药和药物相互作用,对支架后拟行,CABG,者，至少停氯吡格雷,7,天,F3B0y)v%s#pXlUiQfNcK8H5E2A+x*u$rZnWkThPeMaJ7G4C1z-w&t!qYmVjRgOdL9I6F3B0y(v%s#oXlUiQfNbK8H5D2A+x*u$qZnWkShPeMaJ7F4C1z)w&t!pYmUjRgOcL9I6E3B+y(v%r#oXlTiQfNbK8G5D2A-x*u$qZnVkShPdMaJ7F4C0z)w&s!pYmUjRfOcL9H6E3B+y(u%r#oWlTiQeNbJ8G5D1A-x*t$qYnVkSgPdMaI7F3C0z)v&s!pXmUjRfOcK9H6E2B+y(u%rZoWlThQeNbJ8G4D1A-w*t$qYnVjSgPdLaI7F3C0y)v&s#pXmUiRfNcK9H5E2B+x(u$rZoWkThQeMbJ8G4D1z-w*t!qYnVjSgOdLaI6F3C0y)v%s#pXlUiRfNcK8H5E2A+x(u$rZnWkThPeMbJ7G4C1z-w&t!qYmVjRgOdL9I6F3B0y)v%s#oXlUiQfNcK8H5D2A+x*u$rZnWkShPeMaJ7G4C1z)w&t!pYmVjRgOcL9I6E3B0y(v%r#oXlTiQfNbK8G5D2A-x*u$qZnVkShPdMaJ7F4C1z)w&s!pYmUjRgOcL9H6E3B+y(v%r#oWlTiQeNbK8G5D1A-x*t$qZnVkSgPdMaI7F4C0z)v&s!pXmUjRfOcK9H6E2B+y(u%r#oWlThQeNbJ8G5D1A-w*t$qYnVkSgPdLaI7F3C0z)v&s#pXmUiRfOcK9H5E2B+x(u%rZoWkThQeMbJ8G4D1z-w*t!qYnVjSgOdLaI6F3C0y)v&s#pXlUiRfNcK9H5E2A+x(u$rZoWkThPeMbJ7G4D1z-w&t!qYmVjSgOdL9I6F3B0y)v%s#oXlUiQfNcK8H5D2A+x*u$rZnWkThPeMaJ7G4C1z-w&t!pYmVjRgOdL9I6E3B0y(v%s#oXlTiQfNbK8H5D2A-x*u$qZnWkOdL9I6F3B0y)v%s#pXlUiQfNcK8H5E2A+x*u$rZnWkThPeMaJ7G4C1z-w&t!pYmVjRgOdL9I6E3B0y(v%s#oXlTiQfNbK8H5D2A-x*u$qZnWkShPdMaJ7F4C1z)w&t!pYmUjRgOcL9I6E3B+y(v%r#oXlTiQeNbK8G5D2A-x*t$qZnVkShPdMaI7F4C0z)w&s!pXmUjRfOcL9H6E2B+y(u%r#oWlTiQeNbJ8G5D1A-x*t$qYnVkSgPdMaI7F3C0z)v&s!pXmUiRfOcK9H6E2B+x(u%rZoWlThQeMbJ8G4D1A-w*t!qYnVjSgPdLaI6F3C0y)v&s#pXmUiRfNcK9H5E2B+x(u$rZoWkThQeMbJ7G4D1z-w*t!qYmVjSgOdLaI6F3B0y)v%s#pXlUiQfNcK8H5E2A+x*u$rZnWkThPeMbJ7G4C1z-w&t!qYmVjRgOdL9I6F3B0y(v%s#oXlUiQfNbK8H5D2A+x*u$qZnWkShPeMaJ7F4C1z)w&t!pYmUjRgOcL9I6E3B0y(v%r#oXlTiQfNbK8G5D2A-x*u$qZnVkShPdMaJ7F4C0z)w&s!pYmUjRfOcL9H6E3B+y(u%r#oWlTiQeNbJ8G5D1A-x*t$qYnVkSgPdMaI7F4C0z)v&s!pXmUjRfOcK9H6E2B+y(u%rZoWlThQeNbJ8G4D1A-w*t$qYnVjSgPdLaI7F3C0y)v&s#pXmUiRfNcK9H5E2B+x(u%rZoWkThQeMbJ8G4D1z-w*t!qYnVjSgOdLaI6F3C0y)v%s#pXlUiRfNcK8H5E2A+x(u$rZnWkThPeMbJ7G4C1z-w&t!qYmVjSgOdL9I6F3B0y)v%s#oXlUiQfNcK8H5D2A+x*u$rZnWkShPeMaJ7G4C1z)w&t!pYmVjRgOcL9I6E3B0y(v%rkThPeMbJ7G4D1z-w&t!qYmVjSgOdL9I6F3B0y)v%s#oXlUiQfNcK8H5D2A+x*u$rZnWkShPeMaJ7G4C1z)w&t!pYmVjRgOcL9I6E3B0y(v%s#oXlTiQfNbK8H5D2A-x*u$qZnWkShPdMaJ7F4C1z)w&s!pYmUjRgOcL9H6E3B+y(v%r#oWlTiQeNbK8G5D1A-x*t$qZnVkSgPdMaI7F4C0z)w&s!pXmUjRfOcL9H6E2B+y(u%r#oWlThQeNbJ8G5D1A-w*t$qYnVkSgPdLaI7F3C0z)v&s#pXmUiRfOcK9H5E2B+x(u%rZoWlThQeMbJ8G4D1A-w*t!qYnVjSgPdLaI6F3C0y)v&s#pXlUiRfNcK9H5E2A+x(u$rZoWkThPeMbJ7G4D1z-w&t!qYmVjSgOdL9I6F3B0y)v%s#pXlUiQfNcK8H5E2A+x*u$rZnWkThPeMaJ7G4C1z-w&t!pYmVjRgOdL9I6E3B0y(v%s#oXlTiQfNbK8H5D2A-x*u$qZnWkShPeMaJ7F4C1z)w&t!pYmUjNcK8H5E2A+x*u$rZnWkThPeMaJ7G4C1z-w&t!pYmVjRgOdL9I6E3B0y(v%s#oXlUiQfNbK8H5D2A+x*u$qZnWkShPeMaJ7F4C1z)w&t!pYmUjRgOcL9I6E3B+y(v%r#oXlTiQeNbK8G5D2A-x*t$qZnVkShPdMaI7F4C0z)w&s!pYmUjRfOcL9H6E3B+y(u%r#oWlTiQeNbJ8G5D1A-x*t$qYnVkSgPdMaI7F3C0z)v&s!pXmUiRfOcK9H6E2B+x(u%rZoWlThQeNbJ8G4D1A-w*t$qYnVjSgPdLaI7F3C0y)v&s#pXmUiRfNcK9H5E2B+x(u$rZoWkThQeMbJ7G4D1z-w*t!qYmVjSgOdLaI6F3B0y)v%s#pXlUiRfNcK8H5E2A+x(u$rZnWkThPeMbJ7G4C1z-w&t!qYmVjRgOdL9I6F3B0y(v%s#oXlUiQfNbK8H5D2A+x*u$qZnWkShPeMaJ7G4C1z)w&t!pYmVjRgOcL9I6E3B0y(v%r#oXlTiQfNbK8G5D2A-x*u$qZnVkShPdMaJ7F4C0z)w&s!pYmUjRfOcL9H6E3B+y(v%r#oWlTiQeNbK8G5D1A-x*t$qZnVkSgPdMaI7F4C0z)v&s!pXmUjRfOcK9H6E2B+y(u%rZoWPdMaJ7F4C0z)w&s!pYmUjRgOcL9H6E3B+y(v%r#oWlTiQeNbK8G5D1A-x*t$qZnVkSgPdMaI7F4C0z)v&s!pXmUjRfOcK9H6E2B+y(u%rZoWlThQeNbJ8G5D1A-w*t$qYnVkSgPdLaI7F3C0z)v&s#pXmUiRfOcK9H5E2B+x(u%rZoWkThQeMbJ8G4D1z-w*t!qYnVjSgOdLaI6F3C0y)v%s#pXlUiRfNcK9H5E2A+x(u$rZoWkThPeMbJ7G4D1z-w&t!qYmVjSgOdL9I6F3B0y)v%s#oXlUiQfNcK8H5D2A+x*u$rZnWkShPeMaJ7G4C1z-w&t!pYmVjRgOdL9I6E3B0y(v%s#oXlTiQfNbK8H5D2A-t!qYmVjSgOdL9I6F3B0y)v%s#oXlUiQfNcK8H5D2A+x*u$rZnWkThPeMaJ7G4C1z-w&t!pYmVjRgOdL9I6E3B0y(v%s#oXlTiQfNbK8H5D2A-x*u$qZnWkShPdMaJ7F4C1z)w&s!pYmUjRgOcL9I6E3B+y(v%r#oXlTiQeNbK8G5D2A-x*t$qZnVkShPdMaI7F4C0z)w&s!pXmUjRfOcL9H6E2B+y(u%r#oWlThQeNbJ8G5D1A-x*t$qYnVkSgPdMaI7F3C0z)v&s!pXmUiRfOcK9H6E2B+x(u%rZoWlThQeMbJ8G4D1A-w*t!qYnVjSgPdLaI6F3C0y)v&s#pXlUiRfNcK9H5E2B+x(u$rZoWkThQeMbJ7G4D1z-w*t!qYmVjSgOdLaI6F3B0y)v%s#pXlUiQfNcK8H5E2A+x*u$rZnWkThPeMaJ7G4C1z-w&t!qYmVjRgOdL9I6F3B0y(v%s#oXlUiQfNbK8H5D2A+x*u$qZnWkShPeMaJ7F4C1z)w&t!pYmUjRgOcL9I6E3B+y(vnWkThPeMbJ7G4C1z-w&t!qYmVjRgOdL9I6F3B0y(v%s#oXlUiQfNbK8H5D2A+x*u$qZnWkShPeMaJ7F4C1z)w&t!pYmUjRgOcL9I6E3B0y(v%r#oXlTiQfNbK8G5D2A-x*u$qZnVkShPdMaJ7F4C0z)w&s!pYmUjRfOcL9H6E3B+y(u%r#oWlTiQeNbJ8G5D1A-x*t$qZnVkSgPdMaI7F4C0z)v&s!pXmUjRfOcK9H6E2B+y(u%rZoWlThQeNbJ8G4D1A-w*t$qYnVjSgPdLaI7F3C0y)v&s#pXmUiRfNcK9H5E2B+x(u%rZoWkThQeMbJ8G4D1z-w*t!qYnVjSgOdLaI6F3C0y)v%s#pXlUiRfNcK8H5E2A+x(u$rZnWkThPeMbJ7G4C1z-w&t!qYmVjSgOdL9I6F3B0y)v%s#oXlUiQfNcK8H5D2A+x*u$rZnWkShPeMaJ7C0y)v%s#pXlUiRfNcK8H5E2A+x(u$rZnWkThPeMbJ7G4D1z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