冠心病合并心房颤动患者抗凝治疗方案介绍的选择.ppt

冠心病合并心房颤动患者抗凝治疗方案的选择 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 拟择期行PCI者 高危 避免DES，尽可能选择BMS BMS VKA+阿司匹林+氯吡格雷 4周 出血风险高者2-4周 加用PPI 后VKA单药终生 INR 2.0-3.0 DES 雷帕霉素 三联 3个月 2.0-2.5 紫杉醇 三联 6个月 2.0-2.5 后VKA+阿司匹林/波立维至术后12个月 后VKA单药终生抗凝 低中危 低危者，无需VKA治疗，择期PCI依支架术常规抗凝方案 VKA抗凝任何阶段均需密切监测INR及出血倾向 急性冠脉综合征 药物保守治疗 三联 3-6个月 出血风险低者进一步延长时间 加用PPI