关注出血合理选择抗凝治疗 郭丽君.pptVIP

关注出血合理选择抗凝治疗 北京大学第三医院 郭丽君 ACS的病理解剖学基础 抗凝药物的作用部位 Bivalirudin 20 Amino acid polypeptide Direct thrombin inhibitor, not AT dependent Short-half-life of 25 minutes Effective on circulating and clot-bound thrombin Inhibits thrombin-mediated platelet activation No interactions with PF-4 No requirement for anticoagulant monitoring Not associated with HIT ExTRACT-TIMI 25 30天临床净获益依诺肝素具有显著的优势 REPLACE-2 PCI Trial The ACUITY ACS Trial (N=13819): Components of the Ischemic Composite The ACUITY Trial (N=13,819):Predictors of Major Bleeding in ACS OASIS 5: Efficacy and Safety at Day 9 Primary Efficacy OutcomeDeath/MI at 30 Days Death at Study End (3 or 6 months) ACC/AHA PCI Guidelines: Antithrombotic Therapy Class I UFH (C) Bivalirudin or argatroban (HIT) (B) Class IIa Bivalirudin alternative to UFH+GPI (low-risk elective) (B) LMWH alternative to UFH (UA/NSTEMI) (B) Class IIb LMWH alternative to UFH (STEMI) (B) 抗凝药物的常用剂量 UFH：100U/kg i.v. ACT250-300ms（合用GPⅡb/Ⅲa 抑制剂60U/kg,ACT200-250ms），APTT 50-70ms 不应超过48h LMWH：依诺肝素0.3mg/kg i.v. 1mg/kg s.c. B12h 75岁，无负荷量，0.75mg/kg s.c. B12h CrCI30ml/min ，1mg/kg，s.c.qd 黄哒肝癸钠：2.5mg,s.c. qd； CrCI30ml/min，禁用 吡伐卢啶：0.75mg/kg i.v. 1.75kg/kg/h静脉输注至手术结束 * * This meta-analysis, pooling the data from randomized trials of short-term LMWH or UFH compared with placebo or an inactive control, confirms that adding heparin to aspirin reduces the risk of death or MI in UA/NSTEMI patients. * Several studies have tested enoxaparin versus unfractionated heparin in UA/NSTEMI. This slide illustrates the results from a meta-analysis by John Peterson, MD, showing the pooled data from 5 major trials. As shown, there is a 19% reduction in death or MI at 30 days, which is highly significant. * * More direct evidence of the use of bivalirudin in the ACS setting comes from the recently presented ACUITY trial that Gregg Stone, MD led and presented at the 2006 American College of Cardiology Scientific Session. This was a trial that studied moderate risk, unstable ang