围手术期抗血小板策略项美香.ppt

1、 ACC/AHA/SCAI Focused Update of the Guideline for Percutaneous Coronary Intervention2007 Writing Committee MembersSpencer B. King III, MD, MACC, FAHA, FSCAI, Co-ChairSidney C. Smith, MD, FACC, FAHA, Co-ChairJohn W. Hirshfeld, Jr, MD, FACC, FAHA, FSCAIAlice K. Jacobs, MD, FACC, FAHA, FSCAIDouglass A.

2、 Morrison, MD, PhD, FACC, FSCAIDavid O. Williams, MD, FACC, FAHA, FSCAIAntiplatelet TherapyA loading dose of clopidogrel, generally 600 mg, should be administered before or when PCI is performed. Modified recommendationIn patients undergoing PCI within 12 to 24 hours of receiving fibrinolytic therap

3、y, a clopidogrel oral loading dose of 300mg may be considered.Modified recommendationFor all post-PCI stented patients receiving a DES, clopidogrel 75 mg daily should be given for at least 12 months if not at high risk of bleeding.Modified recommendationFor patients receiving BMS, clopidogrel should

4、 be given for a minimum of 1 month and ideally up to 12 months (unless at increased risk of bleeding).Modified recommendationI IIaIIa IIbIbII IIIIIII IIa IIb IIII IIa IIb IIII IIaIIa IIbIbII IIIIIIAntiplatelet TherapyIf clopidogrel is given at the time of procedure, supplementation with GP IIb/IIIa

5、receptor antagonists can be beneficial.ModifiedFor patients with an absolute contraindication to aspirin, it is reasonable to give a 300 mg to 600 mg loading dose of clopidogrel, administered at least 6 hours before PCI, and/or GP IIa/IIIa antagonists at the time of PCI.No ChangeIn patients with inc

6、reased risk of bleeding, a lower dose of 75 mg to 162 mg of aspirin is reasonable during the initial period after stent implantation.NewContinuation of clopidogrel therapy beyond 1 year may be considered in patients undergoing DES placement.NewI IIaIIaIIaIIbIIIIIIIIbI I II IIaIIbIIII IIa IIb IIII II

7、aIIbIIIAntiplatelet TherapyPatients already taking daily long-term aspirin should take 75 mg to 325 mg before PCI.No changesPatients not already taking daily aspirin should be given 300 mg to 325 mg of aspirin at least 2 hours and preferably 24 hours before PCI.No changeAfter PCI, in patients withou

8、t allergy or increased risk of bleeding, aspirin 162 mg to 325 mg daily should be given for at least:1 month after BMS3 months after sirolimus-eluting stent6 months after paclitaxel-eluting stentModified recommendationI IIa IIb IIII IIaIIbIIII IIa IIb IIIAspirinAll post-PCI stented patients without

9、aspirin resistance, allergy, or increased risk of bleeding should be given aspirin 162 mg to 325 mg daily for at least:1 month after BMS 3 months after sirolimus-eluting stent6 months after paclitaxel-eluting stent Long-term aspirin use should be continued indefinitely at 75 mg to 162 mg daily.Modif

10、ied recommendationIn patients at increased risk of bleeding, lower-dose 75 mg to 162 mg of aspirin is reasonable during the initial period after stent implantation.New recommendationII IIaIIII IIbIIIIb IIIIIII IIaIIbIIIAspirin 2006 Consensus of China: ASA100300mg q.d. after PCI at least 1 month. And

11、 then 75100mg q.d. Aspirin No trials compared lower dose(75-162mg) with higher dose aspirin (162-325mg) as the initial course of therapy after DES in subacute or late stent thrombosis The recommendation according to the clinical trial protocol Higher dose aspirin increase the risk of bleeding In the

12、 patients at high risk of bleeding, the use of low dose of aspirin.Aspirin Major bleeding events were more frequently in patients of taking SA 200mg+clopidogrel 75mg than that of taking ASA 100mg + clopidogrel 75mg Antiplatelet effects could not be increased in higher dose of ASA ClopidogrelFor all

13、post-PCI patients who receive a DES, clopidogrel 75 mg daily should be given for at least 12 months if not at high risk of bleeding.For post-PCI patients receiving as BMS, it should be given for a minimum of 1 month and ideally up to 12 months (unless patient is at increased risk of bleeding then it

14、 should be given for a minimum of 2 weeks).Modified recommendationFor all post-PCI non-stented STEMI patients, treatment with clopidogrel should continue for 14 days.New recommendationLong-term maintenance therapy (e.g. 1 year) with clopidogrel is reasonable in STEMI and NSTEMI who undergo PCI without reperfusion therapy. New recommendationII IIaII IIbII IIIIIII IIaIIbIIIII IIaII IIbII IIIIIIPerioperative period Under urgent situation, the duration studied for FDA approval 3 months for SES6 months for PES