袁晋青pci后抗血小板治疗tcc课件

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1、介入术后抗血小板治疗中国医学科学院　阜外心血管病医院袁晋青一．抗血小板药物作用机制和阿司匹林抵抗不同的抗血小板药物作用机制胶原凝血酶TXA2阿司匹林ADP(纤维蛋白原受体）氯吡格雷TXA2ADP双嘧达莫磷酸二酯酶ADPGpIIb/IIIa激活COX盐酸噻氯匹定ADP=adenosinediphosphate,TXA2=thromboxaneA2,COX=cyclooxygenase.SchaferAI.AmJMed.1996;101:199–209.Category%ORAcuteMIAcutestrokePrior

2、MIPriorstroke/TIAOtherhighriskCoronaryarterydisease(unstableangina,heartfailure)Peripheralarterialdisease(intermittentclaudication)22±2%Highriskofembolism(atrialfibrillation)Other(diabetesmellitus)Alltrials1.00.50.01.52.0ControlBetterAntiplateletBetterAntithro

3、mboticTrialists’Collaboration(ATC):EfficacyofAntiplateletTherapyonVascularEvents**Vascularevents=MI,stroke,orvasculardeath.OR,oddsreduction;MI,myocardialinfarction;TIA,tranientischemicattack.AntithromboticTrialists’Collaboration.BMJ.2002;324:71-86.(withpermissio

4、n)AspirinResistance:MoreThanJustaLaboratoryCuriosity?BhattDL.JAmCollCardiol.2004;43:1127-1129.GeneticPolymorphismsCOX-1GPIIIareceptorCollagenreceptorvWFreceptorCellularFactorsInsufficientsuppressionofCOX-1OverexpressionofCOX-2mRNAErythrocyte-inducedplateletacti

5、vationIncreasednorepinephrineGenerationof8-iso-PGF2αClinicalFactorsFailuretoprescribeNoncomplianceNonabsorptionInteractionwithibuprofenInteractionwithnaproxenAspirinResistanceAspirinResistanceandtheRiskofCardiovacularEventsinHighRiskPatients5529ptsfromHOPEstudy

6、withbaselineurinesamplesCase(n=488)PtswithCVeventsafterrandomizationControls(n=488)PtswithoutCVeventsafterrandomizationUrinary11-dehydroThromboxaneB2(ng/mmolcreatinine)<15.115.1-21.821.9-33.8>33.81.01.31.41.8MI,strokeorCVdeath(P=.01)OddRatioHypothesis:Incomplete

7、inhibitionofthromboxaneB2increasesriskofcardiovasculareventAdaptedfromEikelboomJW,etal.Circulation.2002;105:1650-1655.VerifyNow™ASA,ASA/clopidogrel(n=464),26.9%ASAresistantAspirin-resistantAspirin-sensitiven=125P=0.007n=339CVDeathMICVA/TIAHospUACumulativeinciden

8、ceofcompositeendpoint(%)Follow-uptime(days)ASAResponseandLong-TermCVEvents二、氯吡格雷的早期和长期应用－什么时间用？用多长时间？CLARITY急救亚组研究:住院前氯吡格雷对比安慰剂(加溶栓治疗)ECG显示ST段恢复的患者(%)在救护车上给予氯吡格雷的患者伴S