氯吡格与血小板反应.ppt

1,CLEARPLATELETS:,ClopidogrelLoadingwithEptifibatidetoArresttheReactivityofPlatelets,衷汾巷摇炮解卫镊阀霹厦披窿弘棚漠砾阐贮坡瓷腾拯猖斟砰蝉截暗峨屁落氯吡格与血小板反应氯吡格与血小板反应,2,Introduction,Wehavepreviouslyreportedasignificantincidenceofclopidogrelresistanceinpatientspost-electivecoronarystentingtreatedwithastandard300-mgloadingdose1(31%at24hours)Patientswithclopidogrelresistance/highpost-stentplateletreactivitymaybeatgreatestriskofSATandischemicevents2-4Relationofperi-proceduralplateletreactivitytomyocardialnecrosishasneverbeenprospectivelystudiedThesedatasuggestthat300mgclopidogrel/75mgqddoesnotprovidesufficientinhibitioninsomepatientsundergoingelectivecoronarystenting,1.Gurbeletal.Circulation.2003;107:2908.2.Mulleretal.ThrombHaemost.2003;89:783.3.Barraganetal.CatheterCardiovascInterv.2003;59:295.4.Matetzkyetal.Circulation.2004;109:3171.,睛恐氓皆皖尖唇糙醛项异迄摔困惕朔铆驮漠阿扒吸提悬频弗拙罢盟沂珊腰氯吡格与血小板反应氯吡格与血小板反应,3,Introduction(contd),Mechanismsofclopidogrelnonresponse/resistanceareincompletelydefined,Studyof30pts(n=10forticlodipine,n=10forclopidogrel300mg,n=10forclopidogrel600mg)suggestedbetterinhibitionwith600mgat4hoursbutnodifferenceat24hourswith600-mgdose1,1.Mulleretal.Heart.2001;85:92.,从何啥蠕旅镀菠兹簧夏抵官针饺氰航谚笑孩徐努蛹邢伯喉光戌挠晦篷哟碘氯吡格与血小板反应氯吡格与血小板反应,4,Introduction(contd),Alargeprospectivepharmacodynamicstudyofclopidogrel300mgvs600mgisnotavailableTheeffectofaddingeptifibatidetotheseregimensisunknownISARREACTsuggestednobenefitofaddingabciximabtopatientsloadedwith600mgclopidogrel1Patientsallpretreatedfor2hours(median7.4hours)RiskofbleedingwithCABGinpatientsonclopidogreltherapy2Low-riskgroup,1.Kastratietal.NEnglJMed.2004;350:232.2.Hongoetal.JAmCollCardiol.2002;40:231.,胆更菩刺酬兴必耿干男跑函床拨恢跨顷衍灭昆寸执恼孽格复慰裂薛颐沥沸氯吡格与血小板反应氯吡格与血小板反应,5,ObjectivesofCLEARPLATELETSTrial,Compareplateletreactivityfollowing4treatmentsinlow-tomoderate-riskpatientsundergoingelectivestentingWithoutpretreatment(CRUSADE)coronaryanatomyunknownpriortoprocedureDOSING600mgClopidogrel600mgClopidogrel+eptifibatide300mgClopidogrel300mgClopidogrel+eptifibatideAnalyzetherelationofplateletreactivitytopostproceduralmyocardialnecrosisAnalyzetherelationofplateletreactivitytopostproceduralinflammation,Gurbeletal.Circulation.2005;111:1153.,喀夜乌拍疤侩胜烧石焉颈追揪腥抓颧铺刑烁第硷方哲殃兰嘶疯档糙运蝎窥氯吡格与血小板反应氯吡格与血小板反应,6,Methods,ConsecutivepatientsundergoingelectivecoronarystentingExclusioncriteriaChestpain1.5Platelets4.0mg/dLThienopyridineorGPIIb/IIIause,ElevatedcardiacmarkersCVA1-3ULN),CKMB(normal),Gurbeletal.Circulation.2005;111:1153.,锐缅子手霹衙崩哟禁郑匝巩娩赢也课冀耸漠迁墒账令赂腔败坡东闪构艘搪氯吡格与血小板反应氯吡格与血小板反应,18,NoMI,MI,5MADP-InducedAggregation,Meanplateletreactivity(%),P0.01,RelationofMeanPosttreatmentAggregationtoOccurrenceofMI(n=120),NoMI,MI,20MADP-InducedAggregation,Meanplateletreactivity(%),P0.01,Gurbeletal.Circulation.2005;111:1153.,鲁工蔽试撅盎泻阔姿样鸯束伍寇托黍耻瑚觅馆匀圭标的披敖袜虞沤汗常畜氯吡格与血小板反应氯吡格与血小板反应,19,CKMB(1-3XULN),Patients(%),CKMB(3XULN),*,*,*P1-3ULN),CKMB(3ULN),*,*,Patients(%),RelationofPlateletReactivitytoMyocardialNecrosis,0,10,20,30,*PULN),Myoglobin(2XULN),P=0.08,P=0.04,P=0.006,P=0.09,Gurbeletal.Circulation.2005;111:1153.,EARLYCLINICALRELEVANCEOFPLATELETREACTIVITY:MYOCARDIALINFARCTION,梳裸母借阶计唾联番吱诸荆碴厘缘如脯胸贡坡透并寞橇伏粮腹暑绞涉掩勋氯吡格与血小板反应氯吡格与血小板反应,22,Troponin-I(ULN),Myoglobin(2ULN),P=0.08,P=0.04,P=0.006,P=0.09,Patients(%),EarlyClinicalRelevanceofPlateletReactivity:MyocardialInfarction,0,10,20,30,40,50,Gurbeletal.Circulation.2005;111:1153.,0,0,煤廷迂右比茁梅浊铲帕季顿咯肃笛茅牟封中爪饰痹鹅疾窗扳助伪串呻缘啃氯吡格与血小板反应氯吡格与血小板反应,23,Conclusions,PlateletreactivitycorrelatesstronglywiththedevelopmentofperiproceduralmyocardialnecrosisinelectivestentingWhenclopidogrelpretreatmentisnotpossibleorwhenthedurationofpretreatmentisinadequate,astrategyofeptifibatideadministrationshouldbeconsideredsinceitisassociatedwithsuperiorplateletinhibitionandlowermyocardialnecrosisthaneither300mgor600mgclopidogrelaloneIntheabsenceofeptifibatide,astrategyofclopidogrel600mgclearlyprovidessuperiorplateletinhibitioncomparedwiththestandard300-mgdoseA600-mgloadingdoseshouldbecomethenewstandardloadingstrategyforclopidogrelincoronarystenting,Gurbeletal.Circulation.2005;1