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1、支架内血栓In-Stent Thrombosis,北京大学第一医院 李建平,Definite/Confirmed （肯定的）Acute coronary syndrome ANDAngiographic confirmation of thrombus or occlusion ORPathologic confirmation of acute thrombosisProbable （可能的）Unexplained death within 30 daysTarget vessel MI without angiographic confirmation of thrombosis or o
2、ther identified culprit lesionPossible （不能排除的）Unexplained death after 30 days,ARC 支架内血栓定义,支架内血栓的预后,Similar mortality observed for SES and BMS thrombosis,Pooled Data from RAVEL, SIRIUS, C-SIRIUS, E-SIRIUS,支架内血栓发生时间,ST = stent thrombosis; SAT = subacute stent thrombosis;LST = late stent thrombosis; VL
3、ST = very late stent thrombosis.Adapted from Bhatt. J Invasive Cardiol. 2003;15(suppl B):3B.,Stent Thrombosis (%),支架内血栓与抗凝、抗血小板治疗,ASA und Ticlopidine,ASA und Anticoagulation,ASA und Clopidogrel,ASA = Acetylsalicylic acidDES: Drug-eluting stent,Bare Metal Stent,Prasugrel?,DES肯定的ST发生率:Bern - Rotterdam
4、 Cohort Study Daemen, Wenaweser et al. Lancet 2007;369:667-78,N=8146,0,1,2,3,4,Time since PCI in years,0,1,2,3,4,5,Cumulative incidence, %,Incidence density1.0 / 100 pt years,3.3%,3.5,0.53% (95% CI=0.44-0.64)/ year,192 definite ST cases,DES肯定的ST发生率:Bern-Rotterdam Cohort Study 4 YearsWenaweser P et a
5、l. J Am Coll Cardiol 2008, 52, 1134-,0.52% (95% CI=0.42-0.62)/ year between 30 days and 5 years,DES肯定的支架内血栓发生率:Bern-Cohort Study 5 YearsWenaweser P et al. ESC 2008,DES vs BMSA cohort of 9,175 patients treated with either BMS or DES (SES or PES), all patients with angiographically documented ST were
6、identified as cases,Early Stent Thrombosis,RR=0.7695% CI =0.30-1.80P=0.55,RR=0.8095% CI =0.32-2.03P=0.79,Meta-analysisSES vs BMSBavry A et al. Am J Card 2005,Meta-analysisPES vs BMSStone G et al. NEJM 2007,%,%,Very Late ST 1 Year (Per Protocol),P=0.75,P=0.02,%,P=0.30,P=0.03,%,Stone G et al. NEJM 200
7、7;356:998-1008,Kastrati A et al. NEJM 2007;356:1030-9,Sirolimus-Eluting Stent,Paclitaxel-Eluting Stent,SIRTAX Definite ST 4 YearsWindecker S et al ESC 2008,2.0%,1.8%,2.8%,2.4%,3.7%,3.4%,Cumulative Incidence of Definite STin LEADERS (BES vs. SES)Windecker et al. Lancet, 2008, 372, 1163-,Overall Incid
8、ence of ST with DES,ENDEAVOR,XIENCE,BIOMATRIX,High Risk of ST in All-Comer Patient Population and STEMI Patients,%,支架内血栓的病因,STENT THROMBOSIS,PatientGenetic PolymorphismReduced LV-EFAcute Coronary SyndromeHematology Disorder,DrugsResistanceDrug-drug InteractionDuration of AntiplateletTreatement,Vesse
9、l ReactionVessel RemodelingHypersensitivity ReactionDelayed Healing,早期支架内血栓的预测因素:残留夹层/撕裂,Bare Metal StentsMACE 30 daysSchhlen H et al. Circulation 1998,N=2,894,Drug-Eluting StentsMACE 30 daysBiondi-Zoccai G et al. EHJ 2006,N=2,418,%,P=0.01,P=0.01,Residual Dissection: Independent Predictor of MACE (O
10、R=2.9),早期支架内血栓IVUS预测因素 With the Use of Sirolimus-Eluting StentsFujii K et al. J Am Coll Cardiol 2005;45:995-8,Minimal Stent CSA,P0.001,mm2,Stent Expansion,Residual Stenosis,%,P0.001,Stent Underexpansion and Residual Reference Segment Stenosis:Independent Predictors of Early Stent Thrombosis!,P0.001,
11、支架内血栓预测因素药物反应异常 Wenaweser P et al. JACC 2005; 45(11):1748-52,服药后血小板活性与DES ST的关系Buonamici P et al JACC 2007,p0.001,p0.001,p0.001,p=ns,Iakovou et alJAMA 2005,Park et alAm J Card 2006,Airoldi et alCirculation 2007,Kuchulakanti et alCirculation 2006,OR=89.8(29.9-270),HR=19.2(5.6-65.5),HR=13.7(4.0-46.7),
12、OR=4.8(2.0-11.1),Odds/Hazard Ratio,过早停用抗血小板药物是支架内血栓的重要预测因素,支架内血栓发生时的抗血小板治疗 Bern-Rotterdam Cohort Study 5 YearsWenaweser P et al. ESC 2008,Triton TIMI 38 Prasugrel vs. Clopidogrel in ACS Patients With StentsWiviott SD et al. Lancet 2008;371:1353-63,Overall Stent Thrombosis,Early Stent Thrombosis,Late
13、 Stent Thrombosis,Park et alAm J Card 2006,Airoldi et alCirculation 2007,Iakovou et alJAMA 2005,Machecourt et alJACC 2007,OR=1.03(1.00-1.05),OR=1.01(1.00-1.03),OR=2.75(1.55-4.88),Odds Ratio,支架内血栓的预测因素-支架长度,OR=1.02(1.00-1.04),OR=1.08(1.06-1.1),De la Torre et alJACC 2008,Roy et alJ Interv Card 2007,Ku
14、chulakanti et alCirculation 2006,OR=4.4(2.0-10.0),Odds Ratio,支架内血栓的预测因素-分叉病变,OR=2.4(1.1-5.6),Iakovou et alJAMA 2005,OR=6.4(2.9-14.1),Ong et alJACC 2005*,OR=12.9(4.7-35.8),*in setting of AMI,Joner et al JACC 2006,Park et alAm J Card 2006,Daemen et alLancet 2007,Urban et alCirculation 2006,OR=12.4(1.7
15、-89.7),OR=2.3(1.3-4.0),OR=1.8(1.1-2.7),Odds/Hazard Ratio,支架内血栓的预测因素-ACS,De la Torre et alJACC 2008,HR=2.6(1.3-4.9),Impact of Thrombus Burden on Risk of ST With DES in Patients With STEMISianos G et al. J Am Coll Cardiol 2007;50:573-83,Independent Predictors of ST,Kuchulakanti Circ 2006,Urban Circ 20
16、06,IakovouJAMA 2005,DaemenLancet 2007,Machecourt JACC 2007,OR=2.0(0.8-4.9),OR=2.8(1.7-4.3),HR=3.7(1.7-7.9),HR=2.0(1.1-3.8),OR=2.7(1.4-5.2),Odds/Hazard Ratio,支架内血栓的预测因素-糖尿病,IijimaAm J Card 2007,HR=2.2(1.1-4.3),HR=1.75(1.0-3.0),De la TorreJACC 2008,晚期支架内血栓的可能原因,Chronic inflammatory reaction to the polymer or drugHypersensitivity to the polymer or drugFailure of stents to completely reendothelialize completelyLate incomplete stent appositionDisease progression,
