PCI术后低分子肝素应用画龙点睛？or画蛇添足？.ppt

ACC/AHA PCI 2007 If clopidogrel is given at the time of procedure, supplementation with GP IIb/IIIa receptor antagonists can be beneficial (IIa-B) 中国PCI指南 2009 择期PCI的高危患者或高危病变，可应用GPIIb/IIIa 受体拮抗剂 (Ⅱa-B) ESC PCI 2007 行PCI高危患者，给予血小板糖蛋白IIb/IIIa 受体拮抗剂（I-A） GP IIb/IIIa受体拮抗剂必须与抗凝剂合用 （ I-A ） GPIIb/IIIa受体拮抗剂在PCI中应用 GPIIb/IIIa受体拮抗剂联合抗凝剂LMWH UFH A to Z trial First randomized trial of LMWH + GP IIb/IIIa in high-risk ACS patients randomized to enoxaparin (1 mg/kg every 12 hours) or UFH 60% went to Cath Lab Conclusions Conclusion Enoxaparin improves outcomes (both bleeding and efficacy) compared with UFH in patients with ACS with aspirin and eptifibatide Study Design At least 2 of 3 required: Age ? 60 ST ? (transient) or ? (+) CK-MB or Troponin Enoxaparin IV Heparin Primary endpoint: Death or MI at 30 days Randomize(n = 10,000) Early invasive strategy Other therapy per AHA/ACC Guidelines (ASA, ?-blocker, ACE, clopidogrel, GP IIb/IIIa) 60 U/kg ? 12 U/kg/hr (aPTT 50-70 sec) 1 mg/kg SC Q12H 56% GP IIb/IIIa 98% Angiography 48% PCI High-RiskACS Patients PCI术后LMWH能安全与GPIIb/IIIa受体拮抗剂合用 GPIIb/IIIa受体拮抗剂联合LMWH同UFH一样有效 结 论 总 结 PCI术后不推荐常规应用LMWH； 对大部分患者，成功干预和没有并发症PCI术后双联抗血小板治疗足够，联合LMWH并没带来额外获益，增加出血风险，可能有画蛇添足嫌疑； 对高危患者， PCI术后双联抗血小板治疗是必要的，联合LMWH是有效的和安全的，起到画龙点睛作用； PCI术后GPIIb/IIIa受体拮抗剂联合LMWH 与UFH一样有效和安全，但LMWH使用方便、安全，无须特别监测，联合LMWH 更有优势。 * * Although there are a variety of approaches to enhancing anticoagulant effects none are completely satisfactory when used as a single agent. Major categories of anticoagulant therapy include agents that target any one of three main components of the thrombotic process; thrombin, platelets, or fibrin. * LMWH have several advantages over UFH: Longer plasma half-life and better bioavailability after s.c.  administration Less binding to plasma proteins and endothelial cells More predictable anticoagulant response Body-weight-adjusted twice- or once-daily subcutaneous  administration No monitoring of coagulatio