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1、ACSACS患者的管理与心脏康复患者的管理与心脏康复 Hospitalizations in the U.S. Due to ACS Acute Coronary Syndromes 1.57 Million Hospital Admissions - 1.57 Million Hospital Admissions - ACSACS UA/NSTEMISTEMI 1.24 million Admissions per year 0.33 million Admissions per year *Primary and secondary diagnoses. About 0.57 milli
2、on NSTEMI and 0.67 million UA. Heart Disease and Stroke Statistics 2007 Update. Circulation 2007; 115:69171. 3 3 高血压 缺少锻炼饮酒过量 吸 烟 超 重 糖尿病 血脂异常 遗传因素 不合理 膳食结构 控制危险因素控制危险因素 康复治疗康复治疗 内科药物治疗内科药物治疗 CABGPCI ACS患者需要接受综合治疗和管理 ACS ACS 的治疗策略的治疗策略 PCI 溶栓 药药物治疗疗 CABG 抗栓治疗(抗凝和抗血小板治疗) 药物治疗 ADP antagonist Nitrates
3、BBsACEIs CCBs Statins 再灌注和血运重建治疗疗 UHF or LMWH Xa-I ASA GP IIb/ IIIa DTI ARBsAPT ACS 器械相关因素器械相关因素 表面表面 药物药物 涂层涂层 支架重叠支架重叠 病变相关因素病变相关因素 血管、病变长度血管、病变长度 血栓血栓 斑块特点斑块特点 分叉分叉 钙化钙化 CTOCTO 介入手术相关介入手术相关 内膜内膜撕裂撕裂 支架膨胀不全支架膨胀不全 支架贴壁不良支架贴壁不良 支架数量和长度支架数量和长度 血小板和抗凝血小板和抗凝 血小板聚集抑制率血小板聚集抑制率 对抗血小板治疗的不当反应对抗血小板治疗的不当反应 停用
4、抗血小板药物停用抗血小板药物 病人因素病人因素 药物反应性和相互作用药物反应性和相互作用 基因多态性基因多态性 LVEFLVEF ACS ACS 肾衰肾衰 DMDM 支架血栓支架血栓 DES 血栓的相关因素 Windecker and Meier. Circulation 2007;116:1952 支支 架架 内内 血血 栓栓 形形 成成 l l 支架内血栓形成是冠脉介入治支架内血栓形成是冠脉介入治疗严疗严疗严疗严 重的并重的并发发发发症,症,临临临临床床 后果后果严严严严重重 l l 支架内血栓形成的分型:支架内血栓形成的分型: 迟发 晚期血栓 1 年以上 晚期血栓形成 亚急性血栓形成 2
5、4 小时- 30天 术后24 小时内 急性血栓形成 31天 - 1年 7 7 指 南 建 议 抗抗 血血 小小 板板 药药 物物 l l 阿司匹林阿司匹林 所有无禁忌所有无禁忌证证证证的患者的患者应长应长应长应长 期使用阿司匹林期使用阿司匹林75-162mg/d75-162mg/d,如,如 不能耐受可使用不能耐受可使用氯氯氯氯吡格雷(吡格雷(I I,A A) l l P2Y12P2Y12受体抑制受体抑制剂剂剂剂 未行介入治未行介入治疗疗疗疗:氯氯氯氯吡格雷吡格雷75mg/75mg/日日, ,至少至少1 1个月,如果条件个月,如果条件许许许许 可,可可,可应应应应用至用至1 1年;年; (I I
6、,A A) 置入金属裸支架者,置入金属裸支架者,氯氯氯氯吡格雷吡格雷75mg/75mg/日日, ,至少至少1 1个月,最好个月,最好1 1年年 (存在出血高(存在出血高风险风险风险风险 者至少者至少2 2周)周) 置入置入药药药药物支架者,物支架者,氯氯氯氯吡格雷吡格雷75mg/75mg/日,日, 至少至少1 1年年 (I I,A A) 植入药物支架的患者联合抗血小板治疗至少1年 8 8 l l 长长长长期使用期使用剂剂剂剂量:量:75-150mg/d75-150mg/d l l 服服药时间药时间药时间药时间 :早晚均可,:早晚均可,肠肠肠肠溶溶剂应剂应剂应剂应 空腹服用空腹服用 l l 合并
7、胃合并胃肠肠肠肠道副作用的可合用胃粘膜保道副作用的可合用胃粘膜保护剂护剂护剂护剂 或或 质质质质子子泵泵泵泵抑制抑制剂剂剂剂 l l 非甾体非甾体类类类类抗炎抗炎药药药药不能替代阿司匹林不能替代阿司匹林 l l 急性冠脉急性冠脉综综综综合征合征应联应联应联应联 合使用抗血小板合使用抗血小板药药药药物物 阿阿 司司 匹匹 林林 用用 于于 冠冠 心心 病病 的的 治治 疗疗 保守治疗患者的氯比格雷治疗建议保守治疗患者的氯比格雷治疗建议 For UA/NSTEMI patients in whom an initial For UA/NSTEMI patients in whom an initi
8、al conservative strategy is selected conservative strategy is selected clopidogrelclopidogrel should be added to should be added to aspirinaspirin and and anticoagulant therapy anticoagulant therapy as soon as possible as soon as possible after admission and administered for after admission and admi
9、nistered for at at least 1 month and ideally up to 1 year.least 1 month and ideally up to 1 year. I I I IIaIIaIIa IIbIIb IIb III IIIIII I I I IIaIIaIIa IIbIIb IIb III IIIIII I I I IIaIIaIIa IIbIIb IIb III IIIIIIIIaIIaIIa IIbIIb IIb III IIIIII *Some uncertainty exists about optimum dosing of clopidog
10、rel. Randomized trials establishing its efficacy and providing data on bleeding risks used a loading dose of 300 mg orally followed by a daily oral maintenance dose of 75 mg. Higher oral loading doses such as 600 or 900 mg of clopidogrel more rapidly inhibit platelet aggregation and achieve a higher
11、 absolute level of inhibition of platelet aggregation, but the additive clinical efficacy and the safety of higher oral loading doses have not been rigorously established. Modified 2011 强调尽早使用氯吡格雷,也建议长期使用氯吡格雷 行行PCIPCI治疗患者的抗血小板建议治疗患者的抗血小板建议 l l Clopidogrel 300 to 600 mg Clopidogrel 300 to 600 mg shou
12、ld be should be given as early as possiblegiven as early as possible before or at the before or at the timetime of PCI of PCI(IA) IA) Or Or l l Prasugrel 60 mg Prasugrel 60 mg should be given should be given promptly and promptly and no later than 1 hour no later than 1 hour after PCI after PCI once
13、 coronary anatomy is defined and a once coronary anatomy is defined and a decision is made to proceed withdecision is made to proceed with PCI (IB)PCI (IB). . l l Clopidogrel 75 mg daily or prasugrel 10 mg Clopidogrel 75 mg daily or prasugrel 10 mg daily should be given for daily should be given for
14、 at least 12 months at least 12 months (IB)(IB). . I I I IIaIIaIIa IIbIIb IIb III IIIIII I I I IIaIIaIIa IIbIIb IIb III IIIIII I I I IIaIIaIIa IIbIIb IIb III IIIIIIIIaIIaIIa IIbIIb IIb III IIIIII I I I IIaIIaIIa IIbIIb IIb III IIIIII I I I IIaIIaIIa IIbIIb IIb III IIIIII I I I IIaIIaIIa IIbIIb IIb I
15、II IIIIIIIIaIIaIIa IIbIIb IIb III IIIIII I I I IIaIIaIIa IIbIIb IIb III IIIIII I I I IIaIIaIIa IIbIIb IIb III IIIIII I I I IIaIIaIIa IIbIIb IIb III IIIIIIIIaIIaIIa IIbIIb IIb III IIIIII Continuation of Continuation of clopidogrel or prasugrel clopidogrel or prasugrel beyond 15 months beyond 15 month
16、s may be considered in may be considered in patients following DES placement. patients following DES placement. Dipyridamole is not recommended Dipyridamole is not recommended as an as an antiplatelet agent in post-UA/NSTEMI antiplatelet agent in post-UA/NSTEMI patients because it has not been shown to be patients because it has not been shown to