支架内血栓发生时间.ppt

支架内血栓In-StentThrombosis,北京大学第一医院李建平,Definite/Confirmed（肯定的）AcutecoronarysyndromeANDAngiographicconfirmationofthrombusorocclusionORPathologicconfirmationofacutethrombosisProbable（可能的）Unexplaineddeathwithin30daysTargetvesselMIwithoutangiographicconfirmationofthrombosisorotheridentifiedculpritlesionPossible（不能排除的）Unexplaineddeathafter30days,ARC支架内血栓定义,支架内血栓的预后,SimilarmortalityobservedforSESandBMSthrombosis,PooledDatafromRAVEL,SIRIUS,C-SIRIUS,E-SIRIUS,支架内血栓发生时间,ST=stentthrombosis;SAT=subacutestentthrombosis;LST=latestentthrombosis;VLST=verylatestentthrombosis.AdaptedfromBhatt.JInvasiveCardiol.2003;15(supplB):3B.,StentThrombosis(%),支架内血栓与抗凝、抗血小板治疗,ASAundTiclopidine,ASAundAnticoagulation,ASAundClopidogrel,ASA=AcetylsalicylicacidDES:Drug-elutingstent,BareMetalStent,Prasugrel?,DES肯定的ST发生率:Bern-RotterdamCohortStudyDaemen,Wenaweseretal.Lancet2007;369:667-78,N=8146,0,1,2,3,4,TimesincePCIinyears,0,1,2,3,4,5,Cumulativeincidence,%,Incidencedensity1.0/100ptyears,3.3%,3.5,0.53%(95%CI=0.44-0.64)/year,192definiteSTcases,DES肯定的ST发生率:Bern-RotterdamCohortStudy4YearsWenaweserPetal.JAmCollCardiol2008,52,1134-,0.52%(95%CI=0.42-0.62)/yearbetween30daysand5years,DES肯定的支架内血栓发生率:Bern-CohortStudy5YearsWenaweserPetal.ESC2008,DESvsBMSAcohortof9,175patientstreatedwitheitherBMSorDES(SESorPES),allpatientswithangiographicallydocumentedSTwereidentifiedascases,EarlyStentThrombosis,RR=0.7695%CI=0.30-1.80P=0.55,RR=0.8095%CI=0.32-2.03P=0.79,Meta-analysisSESvsBMSBavryAetal.AmJCard2005,Meta-analysisPESvsBMSStoneGetal.NEJM2007,%,%,VeryLateST1Year(PerProtocol),P=0.75,P=0.02,%,P=0.30,P=0.03,%,StoneGetal.NEJM2007;356:998-1008,KastratiAetal.NEJM2007;356:1030-9,Sirolimus-ElutingStent,Paclitaxel-ElutingStent,SIRTAXDefiniteST4YearsWindeckerSetalESC2008,2.0%,1.8%,2.8%,2.4%,3.7%,3.4%,CumulativeIncidenceofDefiniteSTinLEADERS(BESvs.SES)Windeckeretal.Lancet,2008,372,1163-,OverallIncidenceofSTwithDES,ENDEAVOR,XIENCE,BIOMATRIX,HighRiskofSTinAll-ComerPatientPopulationandSTEMIPatients,%,支架内血栓的病因,STENTTHROMBOSIS,PatientGeneticPolymorphismReducedLV-EFAcuteCoronarySyndromeHematologyDisorder,DrugsResistanceDrug-drugInteractionDurationofAntiplateletTreatement,VesselReactionVesselRemodelingHypersensitivityReactionDelayedHealing,早期支架内血栓的预测因素:残留夹层/撕裂,BareMetalStentsMACE30daysSchhlenHetal.Circulation1998,N=2,894,Drug-ElutingStentsMACE30daysBiondi-ZoccaiGetal.EHJ2006,N=2,418,%,P=0.01,P=0.01,ResidualDissection:IndependentPredictorofMACE(OR=2.9),早期支架内血栓IVUS预测因素WiththeUseofSirolimus-ElutingStentsFujiiKetal.JAmCollCardiol2005;45:995-8,MinimalStentCSA,P0.001,mm2,StentExpansion,ResidualStenosis,%,P0.001,StentUnderexpansionandResidualReferenceSegmentStenosis:IndependentPredictorsofEarlyStentThrombosis!,P0.001,支架内血栓预测因素药物反应异常WenaweserPetal.JACC2005;45(11):1748-52,服药后血小板活性与DESST的关系BuonamiciPetalJACC2007,p0.001,p4mmdiameter)vessels,?AMIpts,?lowrestenosisrisklesionsBalloonPCIsidebranchinbifurcations(provisionalstentonly),smallvesselsindistallocations,专家共识,OptimizeDESimplantationtechniquesAdequatelesionpreparation(pre-dilatation)Highpressureimplantationmethodologies(likepreviousBMSstrategies)Avoidundersizingandinflow/outflowobstruction(modstenosesordissections)ImplantstentedgesintonormalreferencessegmentsConsiderIVUSguidance(esp.LAD),专家共识,CarefulexplanationsandopencommunicationwithpatientsandfamiliesCarefulpre-treatmenthistoryDiscussionwithEVERYptre:risksandbenefitsofDESvs.alternativetherapiesOngoing(post