抗血小板治疗及功能检测.pptVIP

亚洲和美国人比较，STEMI比例更高，病情更危重 * 由于亚洲人血小板低反应比例与临床结局之间存在显著差异，因此提出东亚悖论概念 * The formation of a platelet aggregate is initiated by the interaction of platelet surface receptors GPIb?IX?V and GPVI with VWF and collagen, respectively. The initial phase of platelet activation is followed by a shift in the conformation integrins on platelets. GPIIb/IIIa (also known as GPαII/βIII, integrin αIIbβ3, or integrin α3β2) binds VWF and fibrinogen, mediating firm adhesion, spreading, coagulant activity, and aggregation of platelets. Platelet GPIa/IIa (also know as integrin α2β1) is also essential for platelet activation, since it mediates collagen–platelet binding under low-shear-rate conditions (such as those near an atherosclerotic plaque) and promotes the association between collagen and GPVI. ADP further promotes platelets to undergo a shape change, to release granule contents, and to aggregate, whereas TXA2 exerts a positive feedback in terms of activation and recruitment of additional platelets to the primary hemostatic plug. Abbreviations: GP, glycoprotein; TXA2, thromboxane A2; VWF, von Willebrand factor. * In-hospital LTA data showed no difference across bleeding episodes. * * “东亚悖论”机制 本幻灯由Dr. Young-Hung Jeong提供 亚洲ACS患者 疾病危险因素及 药物代谢反应差异被内在促凝性 (炎症、凝血系统、代谢因子等) 所抵消 血液流速： ↓ 血液流变学异常、分支处或狭窄病变处湍流形成 血管壁： ↓ 内皮功能障碍、炎症和动脉粥样硬化 血液成分： ↓ 血小板功能、凝血、纤维蛋白溶解、代谢或激素因子异常 缺血 事件 药代角度新型P2Y12抑制剂或可减少或避免VPR Sch?mig A. N Engl J Med. 2009;361(11):1108-11. 最新临床研究：对STEMI患者，替格瑞洛、普拉格雷治疗后均存在高比例VPR 为一项前瞻性、单中心、单盲研究，55例STEMI患者行直接PCI治疗，随机分为普拉格雷组(60mg/10mg)和替格瑞洛组(180mg/90mgbid)，随访5天，分别在随机时及随机后1,2,6,24h以及5d时检查血小板活性。 Alexopoulos D, Xanthopoulou I, Gkizas V, et al. Circ Cardiovasc Interv. 2012;5(6):797-804. 208PRU (事后分析的临界值) 230PRU (研究设计中的临界值) 采用VerifyNow分析法检测 接受治疗后2h (临界值208PRU): 替格瑞洛组46.2%出现血小板低反应 普拉格雷组34.6%出现血小板低反应 替格瑞洛与普拉格雷在ACS患者中存在 起效延迟及个体间差异 PRU=P2Y12反应单位 RAPID研究：替格瑞洛或普拉格