ACS抗凝治疗新进展与中国专家—共识完善版.ppt

ACS抗凝治疗： 依诺肝素的治疗谱可以贯穿ACS治疗始终， 无论保守还是介入治疗都可带来显著获益 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。 UFH作为辅助抗凝，2007年更新推荐了已确定疗效的UFH给药方案，其中对于PCI患者的抗凝治疗给出了更为详细的推荐：初始接受UFH治疗者，术中需额外静推UFH，应考虑是否接受了GP IIb/IIIa治疗。比伐卢定可能也可以用于初始接受UFH治疗的患者。此外，为减少HIT发生危险，建议抗凝时间48小时的患者，应选择非UFH抗凝治疗方案。 UFH作为辅助抗凝，2007年更新推荐了已确定疗效的UFH给药方案，其中对于PCI患者的抗凝治疗给出了更为详细的推荐：初始接受UFH治疗者，术中需额外静推UFH，应考虑是否接受了GP IIb/IIIa治疗。比伐卢定可能也可以用于初始接受UFH治疗的患者。此外，为减少HIT发生危险，建议抗凝时间48小时的患者，应选择非UFH抗凝治疗方案。 200