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 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. Jac
2、obs, MD, FACC, FAHA, FSCAIDouglass A. 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 h
3、ours 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 recommendationFor patie
4、nts 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 recommendationAntiplatelet TherapyIf clopidogrel is given at the time of procedure, supplementation with GP IIb/IIIa receptor antagonists can be benefic
5、ial.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 lower do
6、se 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 IIaIIbIIII IIaIIbIIII IIaIIbIIIAntiplatelet TherapyPatients already taking daily long-ter
7、m 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 without allergy or increased risk of bleeding, aspirin 162 mg to 325 mg
8、 daily should be given for at least:1 month after BMS3 months after sirolimus-eluting stent6 months after paclitaxel-eluting stentModified recommendationI IIaIIbIIIAspirinAll post-PCI stented patients without aspirin resistance, allergy, or increased risk of bleeding should be given aspirin 162 mg t
9、o 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.Modified recommendationIn patients at increased risk of bleeding, lower-dose 75 mg to 162 mg of
10、aspirin is reasonable during the initial period after stent implantation.New recommendationI IIaIIbIIIAspirinn 2006 Consensus of China: ASA100300mg q.d. after PCI at least 1 month. And then 75100mg q.d. Aspirinn No trials compared lower dose(75-162mg) with higher dose aspirin (162-325mg) as the init
11、ial course of therapy after DES in subacute or late stent thrombosisn The recommendation according to the clinical trial protocoln Higher dose aspirin increase the risk of bleedingn In the patients at high risk of bleeding, the use of low dose of aspirin.Aspirinn Major bleeding events were more freq
12、uently in patients of taking SA 200mg+clopidogrel 75mg than that of taking ASA 100mg + clopidogrel 75mgn Antiplatelet effects could not be increased in higher dose of ASA ClopidogrelFor all post-PCI patients who receive a DES, clopidogrel 75 mg daily should be given for at least 12 months if not at
13、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 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 recommendationI IIaIIbIII
