acs抗栓治疗中实际问题.pptVIP

* * 最重要的是临床意义，这个研究的结论能够给我们带来什么样的临床启示？ 对于接受PCI治疗的ACS患者，每治疗一千个病人使用加倍剂量的波立维，即600毫克的负荷量，150毫克每天的维持量7天，可进一步预防6例心梗和7例的支架血栓形成，而仅仅增加了3例的严重出血，但不增加致死性出血，颅内出血，CABG相关出血或者是TIMI大出血的相关风险。 非PCI治疗的患者应该是持续使用波立维的标准剂量方案。 * Tony In a study by Kim et al, individuals with 2 normal genes were considered homozygous extensive metabolizers of PLAVIX, those with 1 normal and 1 abnormal gene were heterozygous extensive metabolizers, and those with 2 abnormal genes were poor metabolizers. Poor metabolizers were found to have a significantly lower antiplatelet effect and heterozygous extensive metabolizers had reduced antiplatelet effect compared to extensive metabolizers. Therefore, polymorphic CYP2C19 genotypes appear to be major determinants of interindividual variability in PLAVIX responsiveness. Kim KA, Park PW, Hong SJ, Park J-Y. The effect of CYP2C19 polymorphisms on the pharmacokinetics and pharmacodynamics of clopidogrel: a possible mechanism for clopidogrel resistance. Nature. 2008;84:236-242. * 慢代谢者剂量加倍，但长期是否获益有待实 * 在预先设定的PCI队列，分别研究一级疗效终点和二级疗效终点在不同亚组间的均一性。首先观察一级疗效终点，可发现波立维高剂量组的临床获益具有均一性，无论入院诊断、性别、年龄、有无糖尿病史、是否院内使用GP拮抗剂等，高剂量波立维治疗都是明显获益的。另外，最近倍受关注的PPI，在此试验中也得到进一步证实：不论用或不用PPI，都不影响高剂量波立维治疗组的显著获益，这说明PPI不干扰波立维的疗效。本试验观察到了两个显著的交互作用，一个是吸烟，研究发现吸烟者比不吸烟者接受高剂量波立维治疗显著获益。另一个是ASA不同剂量的交互影响，从一级终点可看出，高剂量ASA治疗的患者似乎接受高剂量波立维治疗临床获益更为明显，但从右面一列次级疗效终点分析，吸烟仍然是有显著交互影响的，而此时ASA两个不同剂量组的临床获益没有明显差异了，都表现为接受高剂量波立维治疗明显获益 * * 2010年公布的COGENT研究则是迄今唯一一项评价联用PPI和氯吡格雷对临床终点事件影响的双盲随机对照研究。 研究入组3761例ACS（含PCI）患者，平均随访106天，终点事件为MI、血运重建或卒中等缺血事件 * 研究结果显示，氯吡格雷与PPI联用，对消化道事件风险有显著下降；而对缺血事件的复合终点风险，则并未显示显著差异。 该项研究是PPI与氯吡格雷联用问题的最新证据 * we saw that in fact each LMWH has a specific clinical profile which is related to its PK PD activities, these activities being defined by the chemical structure, this chemical structure being dependent on the manufacturing process. Therefore, we can state that the product is the process. * The answer is definitely that these products are not interchangeable. This statement is endorsed by Health Organization