冠心病合并心房颤动患者抗凝治疗方案的选择.PPTVIP

你们好 冠心病合并心房颤动患者抗凝治疗方案的选择 前言 无论中西方国家，冠心病和房颤都是致残、致死率位居前列的两大心血管疾病，二者在发展和转归上互为恶化，其并存将导致死亡风险加倍。 大量的临床试验证据表明，冠心病依靠抗血小板药物减少心血管事件，房颤则依靠口服抗凝药物降低脑卒中等血栓栓塞事件。冠心病合并房颤的抗凝治疗难点在于这两类药物不能完全替代，而联用抗血小板和抗凝药物又面临着出血增加的风险。 如何在取得最大获益的同时将出血风险降至最低，这是制定冠心病合并房颤抗凝治疗方案的关键。 风险评估（ESC房颤指南） 非瓣膜病房颤的血栓栓塞风险评估 CHA2DS2-VASc 出血风险评估 HAS-BLED 血栓栓塞风险评估CHA2DS2-VASc (a)Risk factors for stroke and thrombo-embolism in non-valvular AF ‘Major’ risk factors ‘Clinically relevant non-major’ risk factors Heart failure or moderate to severe LV systolic dysfunction Hypertension Age 75 years Diabetes mellitus Previous stroke, TIA, or systemic embolism Vascular diseasea Age 65–74 years Female sex (b) Risk factor-based approach expressed as a point based scoring system, with the acronym CHA2DS2-VASc (Note: maximum score is 9 since age may contribute 0, 1, or 2 points) 血栓栓塞风险评估CHA2DS2-VASc  Risk factors Scors Congestive heart failure/LV dysfunction 1 Hypertension 1 Age 75 2 Diabetes mellitus 1 Stroke/TIA/thrombo-embolism 2 Vascular diseasea 1 Age 65–74 1 Sex category (i.e. female sex) 1 Maximum score 9 血栓栓塞风险评估CHA2DS2-VASc  Risk category CHA2DS2-VASc score Recommended antithrombotic therapy One ‘major’ risk factor or 2 ‘clinically relevant non-major’ risk factors 2 OAC One ‘clinically relevant non-major’ risk factor 1 Either OAC or aspirin 75–325 mg daily. Preferred: OAC rather than aspirin No risk factors 0 Either aspirin 75– 325 mg daily or no antithrombotic therapy. Preferred: no antithrombotic therapy rather than aspirin. 出血风险评估HAS-BLED Letter Clinical characteristica Points awarded H Hypertension 1 A Abnormal renal and liver function (1 point each) 1or2 S Stroke 1 B Bleeding 1 L Labile INRs 1 E Elderly (e.g. age 65 years 1 D Drugs or alcohol (1 point each) 1or2 Maximum 9 points 冠心病合并房颤抗凝方案选择 稳定冠心病 急性冠脉综合征 经皮冠状脉介入治疗围手术期 冠脉旁路移植围手术期 冠心病伴心衰 稳定冠心病 药物保守治疗者 栓塞风险 治疗方案选择 高危 VKA单药治疗，不建议加用 阿司匹林 INR 2.0-3.0 阿司匹林（75-150mg）+氯吡格雷75mg 低危或中危伴出血风险 阿司匹林（75-150mg）/氯吡格雷75mg 稳定冠心病