postpci围手术期抗血小板策略项美香.ppt

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/SCAIFocusedUpdateoftheGuidelineforPercutaneousCoronaryIntervention2019WritingCommitteeMembers,SpencerB.KingIII,MD,MACC,FAHA,FSCAI,Co-ChairSidneyC.Smith,MD,FACC,FAHA,Co-Chair,JohnW.Hirshfeld,Jr,MD,FACC,FAHA,FSCAIAliceK.Jacobs,MD,FACC,FAHA,FSCAI,DouglassA.Morrison,MD,PhD,FACC,FSCAIDavidO.Williams,MD,FACC,FAHA,FSCAI,AntiplateletTherapy,Aloadingdoseofclopidogrel,generally600mg,shouldbeadministeredbeforeorwhenPCIisperformed.ModifiedrecommendationInpatientsundergoingPCIwithin12to24hoursofreceivingfibrinolytictherapy,aclopidogreloralloadingdoseof300mgmaybeconsidered.ModifiedrecommendationForallpost-PCIstentedpatientsreceivingaDES,clopidogrel75mgdailyshouldbegivenforatleast12monthsifnotathighriskofbleeding.ModifiedrecommendationForpatientsreceivingBMS,clopidogrelshouldbegivenforaminimumof1monthandideallyupto12months(unlessatincreasedriskofbleeding).Modifiedrecommendation,AntiplateletTherapy,Ifclopidogrelisgivenatthetimeofprocedure,supplementationwithGPIIb/IIIareceptorantagonistscanbebeneficial.ModifiedForpatientswithanabsolutecontraindicationtoaspirin,itisreasonabletogivea300mgto600mgloadingdoseofclopidogrel,administeredatleast6hoursbeforePCI,and/orGPIIa/IIIaantagonistsatthetimeofPCI.NoChangeInpatientswithincreasedriskofbleeding,alowerdoseof75mgto162mgofaspirinisreasonableduringtheinitialperiodafterstentimplantation.NewContinuationofclopidogreltherapybeyond1yearmaybeconsideredinpatientsundergoingDESplacement.New,AntiplateletTherapy,Patientsalreadytakingdailylong-termaspirinshouldtake75mgto325mgbeforePCI.NochangesPatientsnotalreadytakingdailyaspirinshouldbegiven300mgto325mgofaspirinatleast2hoursandpreferably24hoursbeforePCI.NochangeAfterPCI,inpatientswithoutallergyorincreasedriskofbleeding,aspirin162mgto325mgdailyshouldbegivenforatleast:1monthafterBMS3monthsaftersirolimus-elutingstent6monthsafterpaclitaxel-elutingstentModifiedrecommendation,Aspirin,Allpost-PCIstentedpatientswithoutaspirinresistance,allergy,orincreasedriskofbleedingshouldbegivenaspirin162mgto325mgdailyforatleast:1monthafterBMS3monthsaftersirolimus-elutingstent6monthsafterpaclitaxel-elutingstentLong-termaspirinuseshouldbecontinuedindefinitelyat75mgto162mgdaily.ModifiedrecommendationInpatientsatincreasedriskofbleeding,lower-dose75mgto162mgofaspirinisreasonableduringtheinitialperiodafterstentimplantation.Newrecommendation,Aspirin,2019ConsensusofChina:ASA100300mgq.d.afterPCIatleast1month.Andthen75100mgq.d.,Aspirin,Notrialscomparedlowerdose(75-162mg)withhigherdoseaspirin(162-325mg)astheinitialcourseoftherapyafterDESinsubacuteorlatestentthrombosisTherecommendationaccordingtotheclinicaltrialprotocolHigherdoseaspirinincreasetheriskofbleedingInthepatientsathighriskofbleeding,theuseoflowdoseofaspirin.,Aspirin,MajorbleedingeventsweremorefrequentlyinpatientsoftakingSA200mg+clopidogrel75mgthanthatoftakingASA100mg+clopidogrel75mgAntiplateleteffectscouldnotbeincreasedinhigherdoseofASA,Clopidogrel,Forallpost-PCIpatientswhoreceiveaDES,clopidogrel75mgdailyshouldbegivenforatleast12monthsifnotathighriskofbleeding.Forpost-PCIpatientsreceivingasBMS,itshouldbegivenforaminimumof1monthandideallyupto12months(unlesspatientisatincreasedriskofbleedingthenitshouldbegivenforaminimumof2weeks).ModifiedrecommendationForallpost-PCInon-stentedSTEMIpatients,treatmentwithclopidogrelshouldcontinuefor14days.NewrecommendationLong-termmaintenancetherapy(e.g.1year)withclopidogrelisreasonableinSTEMIandNSTEMIwhoundergoPCIwithoutreperfusiontherapy.Newrecommendation,Perioperativeperiod,Underurgentsituation,thedurationstudiedforFDAapproval3monthsforSES6monthsforPES,Predictorsoflatestentthrombosis,SmallvesselsMultiplelesionsLongstentsOverlappingstentsOstialorbifurcationlesionsSuboptimalstentresultLowEFAdvancedageD