特殊情况的抗栓治疗台州.ppt

特殊情况的抗栓治疗 缺血性脑卒中脑出血转化 颅内出血 房颤合并冠心病 围手术期管理 缺血性脑血管疾病患者抗栓治疗 缺血性脑卒中脑出血转化 HI 出血性梗死： HI1 小点状出血 HI2 多个融合的点状出血 PH 脑实质出血 PH1 30%梗死灶有轻微占位效应出血 PH2 30%梗死灶有明显占位效应出血或远离梗死灶出血 缺血性脑卒中出血转化的抗栓治疗 2010 中国卒中急性期指南 缺血性脑卒中出血转化的抗栓治疗 3. 对于出血性脑梗死患者，根据患者的临床情况（无症状和出 血量少）及抗凝适应症时，可以考虑继续抗凝。 Class IIb; Level of Evidence C Guidelines for the Prevention of Stroke in Patients With Stroke and Transient Ischemic Stroke. published online May 1, 2014 特殊情况的抗栓治疗 缺血性脑卒中脑出血转化 颅内出血 房颤合并冠心病 围手术期管理 缺血性脑血管疾病患者抗栓治疗 1. 脑出血后重新开始抗栓治疗的决策制定，依赖于随后的动脉 或静脉血栓栓塞的风险大小、脑出血再发的风险、病人的全 身情况，所以对每个病人必须制定个体化的方案。 *脑梗死风险相对较低病人（如房颤但没有缺血性脑卒中史 ）和脑出血再发风险较高（如高龄的脑叶出血或可疑淀粉样 脑血管病患者）或者整个神经系统功能很差，可以考虑应用 抗血小板药物来预防缺血性脑卒中。 颅内出血后的抗凝治疗 Class IIb; Level of Evidence B Guidelines for the Prevention of Stroke in Patients With Stroke and Transient Ischemic Stroke. published online May 1, 2014 2.对于急性脑出血、蛛网膜下腔出血或硬脑膜下出血后，何时恢 复或开始抗凝治疗，最佳时机尚无定论。大多数病人来说，发 病至少1周以上较为合理 颅内出血后的抗凝治疗: Class IIb; Level of Evidence B Guidelines for the Prevention of Stroke in Patients With Stroke and Transient Ischemic Stroke. published online May 1, 2014 特殊情况的抗栓治疗 缺血性脑卒中脑出血转化 颅内出血 房颤合并冠心病 围手术期管理 缺血性脑血管疾病患者抗栓治疗 For patients with AF and stable coronary artery disease (eg, no acute coronary syndrome within the previous year) who choose oral anticoagulation suggest adjusted-dose VKA therapy alone (target INR range, 2.0-3.0) rather than the combination of adjusted-dose VKA therapy and aspirin (Grade 2C) Antithrombotic Therapy for Atrial Fibrillation Antithrombotic Therapy and Prevention of Thrombosis, 9th ed：American College of Chest Physicians Evidence-Based Clinical Practice Guidelines For patients with AF at intermediate to high risk of stroke (eg, CHADS2 score 1) who experience an acute coronary syndrome and do not undergo intracoronary stent placement suggest for the first 12 months adjusted-dose VKA therapy (INR 2.0-3.0) plus single antiplatelet therapy rather than dual antiplatelet therapy (eg, aspirin and clopidogrel) or triple therapy (eg, warfarin, aspirin, and clopidogrel) (Grade 2C). Antithrombotic Therapy for Atrial Fibrillation Antithrombotic Therapy and Prevention of Thrombosis, 9th ed：American College of Chest Physicians Evidence-Based Clinical Practice Guidelines For patients with AF at intermediate to high risk of stroke After the first 12 months antithrombotic therapy is suggested as for patients with AF and stable coronary artery disease Antithrombotic Therapy for Atrial Fibrillation Antithrombotic Therapy and Prevention of Thrombosis, 9th ed：American College of Chest Physicians Evidence-Based Clinical Practice Guidelines For patients with AF at high risk of stroke (eg, CHADS2 score 2) during the first month after placement of a bare- metal stent or the first 3 to 6 months after placement of a drug-eluting stent suggest triple therapy (eg, VKA therapy, aspirin, and lopid-ogrel) rather than dual antiplatelet therapy(eg, aspirin and clopidogrel) (Grade 2C) Antithrombotic Therapy for Atrial Fibrillation Antithrombotic Therapy and Prevention of Thrombosis, 9th ed：American College of Chest Physicians Evidence-Based Clinical Practice Guidelines For patients with AF at high risk of stroke After this initial period of triple therapy suggest a VKA (INR 2.0-3.0) plus a single antiplatelet drug rather than VKA alone (Grade 2C) . 12 months after intracoronary stent placement antithrombotic therapy is suggested as for patients with AF and stable coronary artery disease Antithrombotic Therapy for Atrial Fibrillation Antithrombotic Therapy and Prevention of Thrombosis, 9th ed：American College of Chest Physicians Evidence-Based Clinical Practice Guidelines patients with nonvalvular AF CHA2DS2-VASc score is recommended for assessment of stroke risk (Level of Evidence: B) high risk of stroke with prior stroke, transient ischemic attack (TIA) or a CHA2DS2-VASc score of 2 or greater 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation For patients with nonvalvular AF oral anticoagulants are recommended Options include: warfarin (INR 2.0 to 3.0) (Level of Evidence: A) dabigatran (Level of Evidence: B), rivaroxaban (Level of Evidence: B) apixaban (Level of Evidence: B) 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation patients with AF undergoing percutaneous coronary intervention bare-metal stents may be considered to minimize the required duration of dual antiplatelet therapy Following coronary revascularization (percutaneous or surgical) in patients with AF and a CHA2DS2-VASc score of 2 or greater, it may be reasonable to use clopidogrel (75 mg once daily) concurrently with oral anticoagulants but without aspirin (Level of Evidence: B) 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation WOEST试验 比较了华法林、氯吡格雷加或不加阿司匹林的双联与三联治疗 结果显示华法林加氯吡格雷的双联治疗 出血风险更低（p0.001）， 1年次要临床终点（包括死亡、心肌梗死、卒中）发生率降低（ p=0.025） 血栓栓塞风险并不增加 指南对这种抗栓方案更为推崇 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation 特殊情况的抗栓治疗 缺血性脑卒中脑出血转化 颅内出血 房颤合并冠心病 围手术期管理 缺血性脑血管疾病患者抗栓治疗 缺血性脑血管疾病患者抗栓治疗 围手术期管理 围手术期的抗血栓形成治疗必须评估 继续用药所致的出血风险 停药所致的血栓栓塞风险 Summary of evidence-based guideline: Periprocedural management of antithrombotic medications in patients with ischemic cerebrovascular disease, Neurology 80 May 28, 2013 缺血性脑血管疾病患者抗栓治疗 围手术期管理 暂停抗栓药物的血栓栓塞风险？ 继续使用抗栓药物的围手术期出血风险？ 如暂停口服抗凝药，需要过渡性治疗吗？ 如果停用抗栓药物，该停多长时间？ Summary of evidence-based guideline: Periprocedural management of antithrombotic medications in patients with ischemic cerebrovascular disease, Neurology 80 May 28, 2013 暂停抗血小板药物 所致血栓栓塞的风险 one Class I study1 and 2 Class II studies 暂停阿司匹林很可能增加脑卒中或短暂性脑缺血发作风险 发生脑卒中风险与阿司匹林停止时间长短相关 停药2周的相对危险度（RR）为1.97 停药4周的比值比（OR）为3.4 停药5月的相对危险度（RR）为1.40 Summary of evidence-based guideline: Periprocedural management of antithrombotic medications in patients with ischemic cerebrovascular disease, Neurology 80 May 28, 2013 暂停抗凝药物所致血栓栓塞风险 不同抗凝适应症，停用抗凝药所致血栓栓塞风险各异。 继续使用华法林和停用华法林（有或没有围手术期肝素过 渡性治疗）条件下血栓栓塞的风险，尚缺乏大样本的研究 。 停用华法林超过7天，导致血栓栓塞的风险高达(RR 5.5) (one Class I study) Summary of evidence-based guideline: Periprocedural management of antithrombotic medications in patients with ischemic cerebrovascular disease, Neurology 80 May 28, 2013 中华医学会心血管病学分会,中华心血管病杂志编辑委员会.中华心血管病杂志,2013.183-194. 如暂停口服抗凝药，需要过渡性治疗吗？ 没有足够证据肝素过渡性治疗减少血栓栓塞事件 大多数研究提示肝素过渡性治疗可能增加围手术期出血风险。 2个一级证据、1个二级证据、1个三级证据的临床研究，肝素过渡性治疗可 增加出血风险 另1个一级证据的临床研究，没有实质性地增加风险。 也没有足够证据发现“继续服用口服抗凝药与肝素过渡性治疗间血栓栓塞风险 差别” 另有1个一级证据临床研究发现，牙科手术，使用低分子肝素过渡性治疗与继 续服用抗凝药相比，出血风险很可能相似。 Summary of evidence-based guideline: Periprocedural management of antithrombotic medications in patients with ischemic cerebrovascular disease, Neurology 80 May 28, 2013 如果停用抗栓药物，该停多长时间？ 尚无足够的证据支持任何明确的结论 抗栓作用时间 阿司匹林和氯吡格雷预计可达7天 单次量的华法林作用时间预计为2-5天 逆转抗栓作用时间，一般推荐 抗血小板药物停止7-10天 华法林停止5天 也有很多回顾性分析，提示停药时间可更短。 Summary of evidence-based guideline: Periprocedural management of antithrombotic medications in patients with ischemic cerebrovascular disease, Neurology 80 May 28, 2013 推 荐 牙科操作，继续使用阿司匹林，很可能（ highly unlikely ）不 增加临床意义的出血性并发症。 缺血性脑卒中患者接受牙科手术时应常规地继续服用阿司匹 林(Level A)。 Summary of evidence-based guideline: Periprocedural management of antithrombotic medications in patients with ischemic cerebrovascular disease, Neurology 80 May 28, 2013 推 荐 继续使用阿司匹林可能（probably）不增加临床意义的出血 性并发症 眼部麻醉、白内障手术、皮肤科小手术和操作、经直肠超 声引导下前列腺穿刺、腰穿/硬膜外操作、腕管手术(Level B) 鉴于很小临床意义出血风险 脑卒中患者接受上述操作时也许应该继续使用阿司匹林 (Level B)。 Summary of evidence-based guideline: Periprocedural management of antithrombotic medications in patients with ischemic cerebrovascular disease, Neurology 80 May 28, 2013 推荐 继续使用阿司匹林可能（might ）不增加临床意义出血并发 症 玻璃体视网膜手术、肌电图、经支气管镜肺活检、肠镜检查 、息肉切除术、胃镜检查和活检、括约肌切开术、腹部超声 引导下活检 较弱证据支持较小临床意义出血风险 高危血栓栓塞风险脑卒中病人接受上述操作时可能应该继续 使用阿司匹林(Level C)。 Summary of evidence-based guideline: Periprocedural management of antithrombotic medications in patients with ischemic cerebrovascular disease, Neurology 80 May 28, 2013 推 荐 虽然出血性不良事件罕见 经尿道前列腺切除术，继续使用阿司匹林增加临床意义出 血风险没有达统计学差异 (Level U). Summary of evidence-based guideline: Periprocedural management of antithrombotic medications in patients with ischemic cerebrovascular disease, Neurology 80 May 28, 2013 推 荐 髋部骨科手术 继续服用阿司匹林很可能（probably）增加出血风险(Level B). Summary of evidence-based guideline: Periprocedural management of antithrombotic medications in patients with ischemic cerebrovascular disease, Neurology 80 May 28, 2013 推 荐 牙科操作，继续使用华法林很可能（highly unlikely）不增加 临床意义的出血性并发症(Level A). 鉴于出血风险小 缺血性脑卒中病人接受牙科操作时应常规继续使用华法林 (Level A). Summary of evidence-based guideline: Pe