口服抗凝药物治疗原则和实践（英文版PPT课件）.pptVIP

Management of Oral Anticoagulant Therapy Principles Practice Prepared for thePostgraduate Education Committee,Council on Clinical CardiologyAmerican Heart Associationby Jack Ansell, M.D. Jack Hirsh, M.D. Nanette K. Wenger, M.D. Supported by an Educational Grant from DuPont Pharmaceuticals Clotting Cascade Vitamin K-Dependent Clotting Factors Vitamin K Mechanism of Action Warfarin Mechanism of Action Warfarin Mechanism of Action Virchow’s Triad Antithrombotic Agents: Mechanism of Action Anticoagulants: prevent clot formation and extension Antiplatelet drugs: interfere with platelet activity Thrombolytic agents: dissolve existing thrombi Warfarin: Indications Prophylaxis and/or treatment of: Venous thrombosis and its extension Pulmonary embolism Thromboembolic complications associated with AF and cardiac valve replacement Post MI, to reduce the risk of death, recurrent MI, and thromboembolic events such as stroke or systemic embolization Prevention and treatment of cardiac embolism Warfarin: Major Adverse Effect—Hemorrhage Factors that may influence bleeding risk: Intensity of anticoagulation Concomitant clinical disorders Concomitant use of other medications Quality of management Special Considerations in the Elderly—Bleeding Increased age associated with increased sensitivity at usual doses Comorbidity Increased drug interactions ? Increased bleeding risk independent of the above Warfarin Dosing in Elderly Patients Prothrombin Time (PT) Historically, a most reliable and “relied upon” clinical test However: Proliferation of thromboplastin reagents with widely varying sensitivities to reduced levels of vitamin K-dependent clotting factors has occurred Concept of correct “intensity” of anticoagulant therapy has changed significantly (low intensity) Problem addressed by use of INR (International Normalized Ratio) INR: International Normalized Ratio A mathematical “correction” (of the PT ratio) for differences in the sensitivity of thromboplastin reagents Relies u