抗凝治疗与出血风险分析.pptVIP

* * * * * 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. * 这是GRACE研究中肾功能损害患者出血及死亡发生率的情况 研究将患者分为3组 肌酐清除率60ml/min(正常或轻度肾损伤) 肌酐清除率30-60ml/min(中度肾损伤) 肌酐清除率30ml/min(重度肾损伤) 结果显示，随着肾损害程度的增加，ACS患者死亡率和大出血的发生率也显著增加。 * * 出血可增加患者的住院时间及花费，增加患者死亡率，那么什么样的ACS患者容易发生出血事件呢？ GRACE研究显示，ACS患者的出血风险独立危险因素分析中，高龄、女性、出血病史及肾功能不全等患者，出血风险均显著增加。 * * * * * 要预防和减少出血事件，首先要了解我们能够做什么。 此表列出了ACS和PCI治疗患者出血风险相关因素，左边的年龄、性别等都是不可变因素，而右边的是可改变的因素，如抗栓药物的选择上，某些药物本质上就有高出血风险的特性。另外，抗栓药物的过量使用也会增加出血风险。 要预防出血事件，除ESC指南提出的要评估出血风险外，要在这些可变因素上下功夫。 由此看来抗栓药物的选择尤为重要。 * 低分子肝素是目前常用的抗凝药物，GRACE研究显示，相比普通肝素，低分子肝素治疗患者，出血发生率显著降低。 左图为单用低分子肝素和普通肝素的比较，右图为联合GpⅡb/Ⅲa抑制剂的比较。 * 本图为低分子肝素和普通肝素的引起大出血风险的比较。 这是一项对多个LMWH与普通肝素比较研究的荟萃分析，共入选13项研究。 通过对不同LMWH组别的研究可以看出，达肝素在几种低分子肝素中具有相对较低的出血风险。 * * ACUITY compared three different pharmacological approaches in intermediate to high-risk patients with NSTE-ACS planned for invasive strategy and revascularisation whenever possible. These were: Conventional anticoagulant plus GP IIb/IIIa inhibitors 比伐卢定 plus GP IIb/IIIa inhibitors 比伐卢定 alone The primary endpoint was a composite of ischemic events and bleeding complications. The composite endpoint was significantly reduced with 比伐卢定 alone as compared patients treated with any combination of anticoagulants and GP IIb/IIIa inhibitors. This result was achieved thanks to a significant risk reduction for major bleeding. Contrary to Oasis-5, the risk reduction for bleeding had no impact on ischemic risk, death, MI or stroke at 30 days or 6 months (recently publish