抗栓治疗中的出血问题ppt课件

Case report 抗栓治疗中的出血问题,The First Affiliated Hospital of HMU,李为民,ACS病理生理学,Fuster et al. N Engl J Med. 1992;326:310-318. Davies et al. Circulation. 1990;82(Suppl II):II-38, II-46.,不稳定血栓(UA/NQMI),脂肪池 巨噬细胞 内在的压力，张力 外部的剪切力,裂缝,大裂缝,小裂缝,闭合血栓 (QwMI),动脉粥样硬化斑块,斑块破裂,血栓,抗栓药物,药物治疗 抗血小板: Aspirin; Clopidogrel Bivalirudin & Hirudin,SYNERGY,1994,1995,1996,1997,1998,1999,2000,2002,2003,2004,2005,2006,2001,Bleeding risk,Ischemic risk,ACUITY,ISAR-REACT 2,Milestones in ACS Management,ICTUS,Adapted from and with the courtesy of Steven Manoukian, MD.,Risk of events,Risk of bleeding,Thrombosis,Hemostasis,Two sides of the same coin,Balancing Events and Bleeding,Case report 1,Backgroud Antiplatelet medications such as clopidogrel and tirofiban (glycoprotien IIb/IIIa inhibitors) are associated with a reduction in mortality and morbidity and are therefore recommended in the treatment of acute coronary syndromes.,Case presentation,A 62 year old man He had previously been well smoked five cigarettes a day for 40 years presented with a three hour history of severe central chest pain associated with sweating and radiating to the neck,Case presentation,blood pressure: 110/82 mm Hg Pulse: 110 beats/min in sinus rhythm ECG: showed widespread ST depression TnT: + Diagnose: Acute coronary syndrome (non-ST segment elevation myocardial infarction ,NSTEMI),Case presentation,He was given intravenous Morphine glyceryl trinitrate Heparin Propranolol aspirin 300 mg+clopidogrel 300 mg followed by maintenance doses of 100 mg and 75 mg,Case presentation,The patients pain did not resolve. ECG showed persistent widespread ST depression,The patients pain resolved and ECG returned to normal within half an hour,Intravenous tirofiban infusion was started with view to emergency cardiac catheterisation,Case presentation,Seven hours later the patient was slightly dyspnoeic at rest,Chest radiograph: bilateral “batwing” shadowing of pulmonary oedema,Case presentation,Seven hours later echocardiogram showed -ejection fraction of 17% -no valvar dysfunction,诊断 ?,ACS (NSTEMI) Pneumonia pulmonary oedema heart failure Others ?,治疗,He was treated for heart failure,?,On the second day,the patient became hypotensive haemoglobin had dropped from 14.5 g/l to 11.6 g/l A Swan-Ganz catheter - mean arterial blood pressure: 70 mm Hg - central venous pressure: 2 mm Hg (05 mm Hg) - PCWP: 2 mm Hg (812 mm Hg) - cardiac index: 2.4 l/min/m2 (2.54.5 l/min/m2) - systemic vascular resistance: 1826 (8001200 dyne/s/cm5),Case presentation,These findings were suggestive of hypovolaemia,The patient was given intravenous fluid resuscitation,Where is bleeding?,Others ?,stomach,Intracal,intra-abdominal,intestinal tract,aortic dissecting aneurysm,Case presentation,There was no - haematemesis - faecal occult blood - intra-abdominal bleeding on CT of the abdomen.,CT of the chest : extensive airspace shadowing in both lung fields,Case presentation,The patient developed recurrent chest pain ECG: bifascicular block He went into cardiac arrest during intubation a large volume of blood was aspirated from the endotracheal tube,pulmonary haemorrhage,autopsy,The patient could not be resuscitated！,讨论 一,死亡原因？ 肺出血及其诊断,Discussion,肺部渗出性病变常见原因 -肺炎常见 -肺水肿常见 -肺出血少见 ACS患者常伴有心功能不全，因该例病人有典型的胸片表现和左室EF值降低，因此，肺部渗出性病变被诊断为肺水肿,Discussion,低血容量和贫血常见原因： 心源性休克 入液量不足 胃肠道出血 腹膜后出血 主动脉夹层动脉瘤 该患有临床出血证据,但是未发现出血来源,Discussion,早期确诊：需做支气管镜检查 阿司匹林+clopidogrel+GPIIb/IIIa inhibitors三联抗血小板时自发大量肺出血少见，容易漏诊，早期识别和治疗能给病人一个存活的机会！,讨论 二,出血是否影响ACS患者预后？,Bleeding Definitions-TIMI,Major ICH Associated with Hgb decrease 5 g/dl or HCT decrease 15% Minor Observed blood loss associated with Hgb decrease 3 g/dl or HCT decrease 10% No identifiable source but Hgb decrease 4 g/dl or HCT decrease 12% Minimal Overt hemorrhage with Hgb drop 3 g/dl or HCT drop 9%,Moscucci M et al. Eur Heart J 2003;24:1815-23.,P0.001,Overall Unstable NSTEMI STEMI ACS Angina,Patients (%),Major Bleeding Predicts Mortality in ACS,24,045 ACS patients in the GRACE registry, in-hospital death,log rank p-value for all four categories 0.0001 log-rank p-value for no bleeding vs. mild bleeding = 0.02 log-rank p-value for mild vs. moderate bleeding 0.0001 log-rank p-value for moderate vs. severe 0.001,Bleeding & Outcomes,Rao SV, et al. Am J Cardiol. 2005 Nov 1;96(9):1200-6.,Kaplan Meier Curves for 30-Day Death, Stratified by Bleed Severity N=26,452 ACS patients from GUSTO IIb, PARAGON A, PARAGON B, & PURSUIT,Major Bleeding, Ischemic Endpoints, Mortality,P0.0001 for all,Manoukian SV, Voeltz MD, Feit F et al. TCT 2006.,Results: The ACUITY Trial PCI Population (N=7,789),在ACS和进行PCI的患者中，出血能增加近期和远期不良事件： 出血病人死亡率增加 出血病人心肌梗死的发生率增加 不良事件风险与出血程度相关，出血程度越重，预后越差。,Bleeding and OutcomesConclusions,ACS 患者如何预测出血风险？,讨论三,P-value,RR (95% CI),Risk ratio 95% CI,Predictors of Major Bleeding,Manoukian SV, Voeltz MD, Feit F et al. TCT 2006.,Results: The ACUITY Trial PCI Population,p0.0001,p=0.0001,REPLACE-2: Elderly Patients,Voeltz MD, Lincoff AM, Feit F, Manoukian SV. Circulation 2005;112(17):II-613. Abstract.,6,002 patients in REPLACE-2 806 patients (13.4%) classified as elderly, 75 years of age,Anticoagulants by Age,Alexander KA, JAMA 2005;294:310816.,12.5,28.7,8.5,33.1,37,12.5,64.5,38.5,16.5,0,10,20,30,40,50,60,70,LMW Heparin,UF Heparin,GP Iib/IIIa,% RBC Transfusion,65 yrs,6575 yrs,75 yrs,Excess Dosing of Gp IIb/IIIa and Bleeding in Women,N=32,601 patients from CRUSADE,Alexander KP, et. al. Circulation 2006,Major Bleeding is Increased in Anemic Patients Undergoing PCI,6,010 patients in REPLACE-2. 1,362 patients (22.7%) classified as anemic. Major bleeding = 3.2%,Major Bleeding,2.8%,4.9%,P=0.0001,Protocol definition: 3g/dL drop in HgB, intracranial, retroperitoneal, 2U transfusion,Voeltz MD, et as. J Am Coll Cardiol 2005;45(3)Suppl A:1037-13-31A.,NSTE-ACS Mortality Stratified by hemoglobin,Sabatine MS. Circulation 2005,Unadjusted,Hb (g/dL) n OR (95% Cl) OR (95% Cl) P value 17 216 1.47 (1.032.10) 1.45 (0.942.23) 0.093 1617 812 1.21 (0.971.51) 1.27 (0.981.65) 0.066 1516 2130 1.0 reference 1.0 reference 1415 3390 1.06 (0.891.22) 1.11 (0.931.33) 0.251 1314 3520 1.02 (0.881.19) 1.04 (0.861.24) 0.709 1213 2331 1.09 (0.921.28) 1.07 (0.881.30) 0.514 1112 976 1.20 (0.971.47) 1.04 (0.811.34) 0.755 1011 343 1.41 (1.051.89) 1.29 (0.921.82) 0.145 910 342 2.44 (1.883.18) 2.69 (2.013.60) 0.001 89 306 2.24 (1.692.96) 2.45 (1.803.33) 0.001 8 137 3.97 (2.765.70) 3.49 (2.355.20) 0.001,Unadjusted and adjusted odds ratios for cardiovascular mortality in patients with non-ST elevation acute coronary syndromes at 30 days stratefied by hemoglobin,Adjusted for baseline characteristics,Bleeding PredictorsConclusions,Independent Predictors of Major Bleeding in Marker Positive ACS,Moscucci, GRACE Registry, Eur Heart J. 2003 Oct;24(20):1815-23.,Older Age Female Gender Anemia Renal Failure History of Bleeding Right Heart Catheterization GPIIb-IIIa antagonists,该病人是否应该输血？,讨论四,Rao SV, et. al., JAMA 2004;292:15551562,Transfusion in ACS,N=24,111,