ACS合并消化道出血治疗策略朱国英.ppt

* Characteristics of the PCI procedure itself are also associated with bleeding complications. An analysis of the REPLACE-2 trial finds not only the expected patient characteristics, such as age, CKD, and anemia, but also finds that long procedures and, importantly, sheath dwell time, also place patients at risk for bleeding. Therapies that minimize sheath dwell time can reduce the risk for periprocedural bleeding. * * * According to the consensus document: If a patient needs antiplatelet therapy, the clinician should assess the patient’s GI risk factors. [Bhatt p7] If the patient has a history of ulcer complication or of nonbleeding ulcer disease, evaluate whether H pylori infection is present and treat if indicated, before starting chronic antiplatelet tharapy. [Bhatt p7,8] Proton pump inhibitors should be prescribed if the patient has GI bleeding, is receiving dual antiplatelet therapy, or is receiving a concomitant anticoagulant. [Bhatt p7] If none of these risk factors are present, the patient should still receive a proton pump inhibitor if more than one of the following apply: [Bhatt p7] The patient is age 60 or older The patient uses corticosteroids The patient has dyspepsia or symptoms of gastroesophageal reflux disease. Bhatt DL, Scheiman J, Abraham NS, et al. ACCF/ACG/AHA 2008 expert consensus document on reducing the gastrointestinal risks of antiplatelet therapy and NSAID use. Circulation 2008 in press; epub Oct 3 ahead of print. * * ACS results from a common pathophysiological mechanism, i.e. plaque rupture or erosion leading to activation of platelet functions, activation of the coagulation cascade and thrombus formation. There are two different clinical presentations: ACS with ST segment elevation, corresponding to a total occlusion of a major epicardial vessel; and ACS without ST segment elevation, usually corresponding to a partially or intermittently occlusive thrombus. The therapeutic approach is different for each of these clinical presentation