1、post-PCI围手术期抗血小板策略,浙江大学医学院附属第二医院心内科 项美香,ACC/AHA/SCAI Focused Update of the Guideline for Percutaneous Coronary Intervention2007 Writing Committee Members,Spencer B. King III, MD, MACC, FAHA, FSCAI, Co-ChairSidney C. Smith, MD, FACC, FAHA, Co-Chair,John W. Hirshfeld, Jr, MD, FACC, FAHA, FSCAIAlice K.
2、 Jacobs, MD, FACC, FAHA, FSCAI,Douglass A. Morrison, MD, PhD, FACC, FSCAIDavid O. Williams, MD, FACC, FAHA, FSCAI,Antiplatelet Therapy,A loading dose of clopidogrel, generally 600 mg, should be administered before or when PCI is performed. Modified recommendationIn patients undergoing PCI within 12
3、to 24 hours of receiving fibrinolytic therapy, 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 recommendationFo
4、r patients receiving BMS, clopidogrel should be given for a minimum of 1 month and ideally up to 12 months (unless at increased risk of bleeding).Modified recommendation,Antiplatelet Therapy,If clopidogrel is given at the time of procedure, supplementation with GP IIb/IIIa receptor antagonists can b
5、e 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 increased risk of bleeding, a
6、 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.New,Antiplatelet Therapy,Patients already taking daily long-term aspirin should take
7、75 mg to 325 mg before PCI. No changes Patients 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 change After PCI, in patients without allergy or increased risk of bleeding, aspirin 162 mg to 325 mg daily should be g
8、iven for at least: 1 month after BMS 3 months after sirolimus-eluting stent 6 months after paclitaxel-eluting stent Modified recommendation,Aspirin,All post-PCI stented patients without aspirin resistance, allergy, or increased risk of bleeding should be given aspirin 162 mg to 325 mg daily for at l
9、east: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.Modified recommendationIn patients at increased risk of bleeding, lower-dose 75 mg to 162 mg of aspirin is reasonable d
10、uring the initial period after stent implantation.New recommendation,Aspirin,2006 Consensus of China: ASA100300mg q.d. after PCI at least 1 month. And 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
11、subacute or late stent thrombosisThe recommendation according to the clinical trial protocolHigher dose aspirin increase the risk of bleedingIn the 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+clo
12、pidogrel 75mg than that of taking ASA 100mg + clopidogrel 75mgAntiplatelet effects could not be increased in higher dose of ASA,Clopidogrel,For all 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 patien
13、ts 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 should be given for a minimum of 2 weeks).Modified recommendationFor all post-PCI non-stented STEMI patients, treatment with clopidogrel should contin
14、ue 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 recommendation,Perioperative period,Under urgent situation, the duration studied for FDA approval 3 months for SES6 months
15、for PES,Predictors of late stent thrombosis,Small vesselsMultiple lesionsLong stentsOverlapping stentsOstial or bifurcation lesionsSuboptimal stent resultLow EFAdvanced ageDMRenal failureASC,Perioperative period,Elective surgery: postponed for 1 yearNot be deferred surgery, aspirin therapy considered in high risk patients with DESSurgery with low risk of bleeding, continue DAT,谢谢,
