新型口服抗凝药的效应和风险.pptVIP

NOACs停药和重启时间 何时停止NOACs 何时重启NOACs 手术出血风险 手术若能完全止血:术后6-8h即可重启 没有临床大出血和/或局部止血:最后一次服药后18-24h 多数手术在术后48-72h重启NOACs会增加出血风险，需考虑没有有效拮抗剂，可能需要二次手术 轻微出血:最后一次服药后24h 大出血:最后一次服药后48h 若术后制动增加DVT风险，术后6-8h起始LMWH，48-72h后重启NOACs 经导管射频消融：术前12-24小时停用NOACs，术中ACT监测下进行肝素化，手术完成拔除鞘管后当晚或次日恢复使用NOACs。 急诊外科：应停用NOACs，若手术可以推迟，至少在末次给药12h（最好为24h）后进行手术；若手术不能推迟，术前需要评估出血风险与手术紧急性。 出血并发症的处理 服用NOACs发生出血 轻度出血 中度至重度出血 致命性出血 延缓或暂停给药 对症治疗 压迫止血 手术治疗止血 补液和血管活性药物 输注血液制品 口服活性炭(2小时内) 血液透析 PCC或rFVIIa* 活性炭滤过* PCC:凝血酶原复合体浓缩物； rFVIIa:重组活化VII因子 *仅仅基于非临床数据的治疗推荐，尚无在健康志愿者或患者中的使用经验 总结展望 新型口服抗凝药的出现将给房颤卒中预防带来新的选择，但尚不能完全取代华法林，需要更多临床试验支持 . 应用优势 未解决问题 改善了有效性 提高了安全性 增加了简便性 如何监测药物浓度？ 如何处理出血，拮抗剂？ 联合抗血小板药物？ 安全性监测的有效手段？ 如何降低价格？ * * Thrombi are composed of fibrin and blood cells. The relative proportion of one type of cell to another and to fibrin is influenced by hemodynamic factors; therefore, the proportions differ in arterial vs venous thrombosis. Arterial thrombi formed under conditions of high flow are composed mainly of platelet aggregates bound together by fibrin strands. The resulting thrombi are sometimes referred to as white thrombi because they have few red blood cells. These thrombi are usually flat, tightly adherent, and relatively small. Arterial thrombi usually occur in association with preexisting vascular disease, the most common of which is atherosclerosis. They produce clinical manifestations by inducing tissue ischemia, primarily through the obstruction of local blood flow. Venous thrombi form in areas of stasis and are composed of red cells with a large amount of interspersed fibrin and relatively fewer platelets. These red thrombi are large, friable casts of the venous channel with branching arms that may extend into tributary veins. Too often such thrombi have only a weak proximal attachment to the venous intima, usually at a valve or a bifurcation, and may detach and embolize to occlude downstream vessels. Venous thrombi usually occur in the lower limbs, particularly in the deep veins of the calf or thigh.