糖尿病ACS患者抗血小板治疗.ppt

糖尿病ACS患者抗血小板治疗 首都医科大学附属北京友谊医院 心血管中心 李虹伟 NCEP-ATPIII: 糖尿病是心血管疾病的等危症 中国心脏调查 糖代谢状态(STEMI+NSTEMI) 血小板在血栓形成中的作用  女性健康研究(WHS)阿司匹林显著降低女性脑卒中/脑梗死危险 2007年ADA/AHA联合指南一级预防推荐 2型糖尿病伴以下任一高危因素者，应用阿司匹林75–162mg/日一级预防心脑血管疾病(A) △ 年龄＞ 40岁 △ 吸烟 △ 肥胖 △ 高血压 △ 血脂异常 △ 蛋白尿 △ 冠心病家族史 糖尿病患者促CAD的原因 糖尿病患者的血小板功能变化 ? 膜Ca+2和Mg+2 代谢障碍 ? 花生四烯酸代谢 ? TXA2 合成 ? 前列腺环素 ? NO 生成 ? 抗氧化能力 ? 激活依赖的粘联分子 (eg, GP IIb/IIIa, P-selectin) 合并糖尿病的CAD患者 TRITON-TIMI 38(TRial to Assess Improvement in Therapeutic Outcomes by Optimizing Platelet InhibitioN with Prasugrel-Thrombolysis in Myocardial Infarction) TRITON-TIMI38: 结果 (1) TRITON-TIMI38: 结果 (2) TRITON-TIMI38: 结果 (4) The likelihood of dosing errors with antithrombotic agents, including UFH, LMWH, and GP IIb/IIIa inhibitors, in patients with NSTE ACS and the association between these errors in dosing and major bleeding was investigated in 30,000 patients with UA/NSTEMI from the CRUSADE registry database. The analysis showed that 42% of patients with NSTE ACS who were administered antithrombotic agents received ≥1 initial dose outside the recommended dose range. Factors associated with a greater vulnerability to excess dosing were older age, including patients 65 and older, but especially those ≥75 years of age; female sex; renal insufficiency; low body weight with an increasing risk for every 5-kg decrease in weight; diabetes; and congestive heart failure. Patients who received excess doses of UFH, LMWH, and GP IIb/IIIa inhibitors tended toward or had higher risks of bleeding compared with those who received recommended doses. Major predictors of overdosing Figure 1. Kaplan–Meier curves for prasugrel vs clopidogrel stratified by diabetes status. A, Primary efficacy end point (cardiovascular death/nonfatal MI/nonfatal stroke) stratified by diabetic status. B, MI (fatal or nonfatal). C, Definite or probable stent thrombosis. D, TIMI major bleeding not related to CABG. E, Net benefit end po