ACS治疗与出血风险课件.ppt

* 减少出血的策略 确定每一个体的出血风险 (年龄、性别、体重、肌酐清除率、出血史 …） 合理使用抗血栓药 使用最低有效剂量（根据年龄、肾功能） ，尤其是联合用药 除非有确凿的适应证，否则避免联用抗血栓药 优先采用桡骨血管通路，其次为股骨血管通路，或使用闭合装置 发生出血后，使用确实能减少出血的药物 评估出血风险是决定治疗策略的重要内容之一。出血风险的增加常与如下因素相关，大剂量或过量的抗栓治疗，疗程过长，多个抗栓药联用，切换不同的抗栓药，以及高龄，肾功能减退，低体重，女性，低基线血红蛋白和侵入性治疗(I-B) 决定治疗策略时应将出血风险考虑进去。对于有高出血风险的患者，应采用已知可降低出血风险的药物、联合用药和非药物方法(如血管途径)(I-B)。 ACS治疗指南对出血风险的评估 Jean-Pierre Bassand, et al. Eur Heart J (2007) 28, 1598–1660 对于小出血的情况应在不中断积极治疗前提下加以控制(I-C)。 除非通过特殊介入治疗能完全控制出血，大出血时必须中断或中和抗凝和抗血小板治疗(I-C)。 因输血对预后有不良影响，应个体化处理对策，并禁止给予血液动力学稳定红细胞压积25%或血红蛋白 8g/L 的患者输血(I-C)。 ACS治疗指南对出血风险的评估 Jean-Pierre Bassand, et al. Eur Heart J (2007) 28, 1598–1660 总 结 ACS治疗应综合考虑缺血与出血的风险 出血风险与年龄、性别、体重、肌苷清除率等相关 ACS患者大出血与死亡率密切相关 制定治疗方案时应该将出血风险考虑在内 合理选择低出血风险的药物、联合用药和非药物方法 * * 国际血栓形成和止血学会（ISTH） GUSTO: 国际随机试验比较四种急性心肌梗死溶栓方案治疗 (包括SK加皮下肝素、SK加静脉肝素、t－PA加静脉肝素、t－PA加SK加静脉肝素。 ) GUSTO试验证实t－PA加静脉肝素是目前AMI病人溶栓治疗的较优方案。 * * However, enoxaparin was associated with an increased risk of bleeding complications, according to both GUSTO and TIMI criteria. * * * * Overall, 12% (593/4993) of patients assigned to enoxaparin received UFH and 4% (205/4985) of patients assigned to UFH received enoxaparin after randomization (crossovers). Analyses of the impact of this postrandomization crossover are complicated because it is an event that occurs after randomization and is further confounded by the knowledge of the treatment assignment. Overall, it appears that changing antithrombin therapy during the treatment course is not associated with any treatment benefit and is associated with an increased risk of bleeding. * * * * * * * An association between the occurrence of bleeding complications and increased mortality was evidenced in the GRACE Registry. * According to the GUSTO definition of bleeding, severe or life-threatening bleeding is defined as intracranial hemorrhage or bleeding that causes hemodynamic compromise and requires intervention; moderate bleeding is defined as bleeding that requires blood transfusion but does not result i