课件：ACS领域抗凝治疗新进展.ppt

THANK YOU SUCCESS * * 可编辑 * Lecture Notes ISIS-2, the Second International Study of Infarct Survival, randomized 17,187 patients with suspected acute myocardial infarction (AMI) at 417 hospitals to streptokinase (SK) alone, aspirin alone, SK plus aspirin, or placebo. The percentage of vascular deaths for SK versus placebo in weeks 1 through 5 was 9.2% for SK and 12.0% for placebo (2P0.00001), a highly significant 25% reduction in the odds of death in the SK group. (ISIS-2, 1988) GUSTO-I, Global Utilization of Streptokinase and Tissue Plasminogen Activator for Occluded Coronary Arteries, was a trial in which 41,021 patients with suspected AMI were randomized to either t-PA plus intravenous heparin, SK plus intravenous heparin, SK plus subcutaneous heparin, or t-PA plus SK. (Califf et al, 1997) There was a statistically significant 14% relative reduction in 30-day mortality with t-PA versus the SK groups. The International Joint Efficacy Comparison of Fibrinolytics (INJECT) trial randomized 6,010 patients to either SK (1.5 MU [mouse units] over 60 minutes) or r-PA (two 10-U boluses given 30 minutes apart). The purpose of the study was to determine whether the survival effect of r-PA was at least equivalent (within 1% of fatality rate) to that of SK. (INJECT, 1995) 35-day mortality was 9.0% for r-PA versus 9.5% for SK (P=0.0003)—a statistically significant difference demonstrating that r-PA is equivalent to SK. * 目前大家都已接受ACS患者应该给与两联抗血小板治疗的观点，但对于一些具体问题还存在一些争议，例如治疗的时间、剂量、疗程、患者人群等等 * 美国心脏病学学会（ACC）/美国心脏协会（AHA）指南、美国胸科医师学会（ACCP）指南等众多权威指南均肯定了抗凝治疗在STEMI患者的整体治疗策略中所起的重要作用，抗凝治疗具有促进和维持冠脉再灌注，限制心肌梗死进展，加强心肌恢复和降低事件再发可能的作用。 * 常用的抗凝药物有普通肝素、低分子肝素、直接凝血酶抑制剂和人工合成的抗Xa因子抑制剂，鉴于能抑制凝血级联反应的众多药物除抑制凝血酶外，还可能抑制蛋白酶，更新了2004版指南6.3.1.6.8.1部分 “抗凝血酶（antithrombins）治疗作为再灌注治疗的辅助治疗”中的术语“抗凝血酶（antithrombins）”修改为“抗凝（anticoagulant）”，。 * UFH用于STEMI已超过40年，但对于UFH的有效性仍争论不止， Eikelboom等针对在STEMI患者中进行的4项UFH试验进行了荟萃分析，与安慰剂或空白对照相比静脉给UFH不仅不能减少死亡/再梗死的发生，还增加了出血危险，且因为颅内出血增高相应地UFH组卒中发生率也高于对照组，分别为11例终点事件（1.8%）和4例终点事件（0.7%）