非st段抬高型心肌梗死诊治进展,从病理到临床.pptVIP

* * * 特殊人群的抗血小板治疗 --老年人 治疗决策需个体化 老年人同样从ASA+氯吡格雷的治疗方案中获益 急性期抗血小板药物负荷剂量应酌情降低或不用, ASA+氯吡格雷长期治疗剂量无需改变，阿司匹林的剂量建议不要超过100mg 特殊人群的抗血小板治疗--手术或有创操作时的处理 择期手术 需平衡手术带来出血和停药后血栓事件风险,决定是否停用抗血小板治疗 紧急手术 服阿司匹林和/或氯吡格雷的患者,需紧急进行外科手术或围术期有威胁生命的出血风险时，建议输血小板或给予止血药物，如氨甲环酸 特殊人群的抗血小板治疗--肾功能不全患者 是ACS预后不良的独立危险因素 目前无证据显示，对于肾功能不全患者需要调整阿司匹林及氯吡格雷的剂量 要正确评价肾功能，并据此调节GPIIb/IIIa受体拮抗剂的剂量。严重肾功能不全的患者（肌酐清除率30%）应减量 对于小出血的情况应在不中断积极治疗前提下加以控制(I-C)。 除非通过特殊介入治疗能完全控制出血，大出血时必须中断或中和抗凝和抗血小板治疗(I-C)。 因输血对预后有不良影响，应个体化处理对策，并禁止给予血液动力学稳定红细胞压积25%或血红蛋白 8g/L 的患者输血(I-C)。 ACS治疗指南对出血风险的评估 Jean-Pierre Bassand, et al. Eur Heart J (2007) 28, 1598–1660 结 语 收益 ? 血栓事件 风险 ? 出血 关键影响因素 抗栓治疗: ASA, UFH, LMWH, GP IIb/IIIa, 氯吡格雷, 溶栓药, 联合用药 患者因素 (高龄, 肾功能下降等) 操作方式 * * 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