特殊情況的抗栓治療臺州

1、缺血性腦卒中腦出血轉(zhuǎn)化缺血性腦卒中腦出血轉(zhuǎn)化 HI 出血性梗死：HI1 小點狀出血HI2 多個融合的點狀出血 PH 腦實質(zhì)出血PH1 30%梗死灶有輕微占位效應出血PH2 30%梗死灶有明顯占位效應出血或遠離梗死灶出血缺血性腦卒中出血轉(zhuǎn)化的抗栓治療缺血性腦卒中出血轉(zhuǎn)化的抗栓治療2010 中國卒中急性期指南缺血性腦卒中出血轉(zhuǎn)化的抗栓治療缺血性腦卒中出血轉(zhuǎn)化的抗栓治療3. 對于出血性腦梗死患者，根據(jù)患者的臨床情況（無癥狀和出對于出血性腦梗死患者，根據(jù)患者的臨床情況（無癥狀和出血量少）及抗凝適應癥時，可以考慮繼續(xù)抗凝。血量少）及抗凝適應癥時，可以考慮繼續(xù)抗凝。Class IIb; Level of

2、Evidence CGuidelines for the Prevention of Stroke in Patients With Stroke and Transient Ischemic Stroke. published online May 1, 2014特殊情況的抗栓治療特殊情況的抗栓治療缺血性腦卒中腦出血轉(zhuǎn)化顱內(nèi)出血房顫合并冠心病圍手術期管理缺血性腦血管疾病患者抗栓治療1. 腦出血后重新開始抗栓治療的決策制定，依賴于腦出血后重新開始抗栓治療的決策制定，依賴于隨后的動脈隨后的動脈或靜脈血栓栓塞的風險大小、腦出血再發(fā)的風險、病人的全或靜脈血栓栓塞的風險大小、腦出血再發(fā)的風險、病人的全

3、身情況身情況，所以對每個病人必須制定個體化的方案。，所以對每個病人必須制定個體化的方案。 *腦梗死風險腦梗死風險相對較低相對較低病人（如房顫但沒有缺血性腦卒中史）病人（如房顫但沒有缺血性腦卒中史）和腦出血再發(fā)和腦出血再發(fā)風險較高風險較高（如高齡的腦葉出血或可疑淀粉樣腦（如高齡的腦葉出血或可疑淀粉樣腦血管病患者）或者整個神經(jīng)系統(tǒng)功能很差，可以考慮應用血管病患者）或者整個神經(jīng)系統(tǒng)功能很差，可以考慮應用抗抗血小板藥物血小板藥物來預防缺血性腦卒中。來預防缺血性腦卒中。顱內(nèi)出血后的抗凝治療顱內(nèi)出血后的抗凝治療Class IIb; Level of Evidence BGuidelines for the

4、 Prevention of Stroke in Patients With Stroke and Transient Ischemic Stroke. published online May 1, 20142.對于急性腦出血、蛛網(wǎng)膜下腔出血或硬腦膜下出血后，何時對于急性腦出血、蛛網(wǎng)膜下腔出血或硬腦膜下出血后，何時恢復或開始抗凝治療，最佳時機尚無定論。大多數(shù)病人來說，恢復或開始抗凝治療，最佳時機尚無定論。大多數(shù)病人來說，發(fā)病至少發(fā)病至少1周以上較為合理周以上較為合理顱內(nèi)出血后的抗凝治療顱內(nèi)出血后的抗凝治療:Class IIb; Level of Evidence BGuidelines fo

5、r the Prevention of Stroke in Patients With Stroke and Transient IschemicStroke. published online May 1, 2014特殊情況的抗栓治療特殊情況的抗栓治療缺血性腦卒中腦出血轉(zhuǎn)化顱內(nèi)出血房顫合并冠心病圍手術期管理缺血性腦血管疾病患者抗栓治療For patients with AF and stable coronary artery disease (eg, no acute coronary syndrome within the previous year) who choose oral a

6、nticoagulation 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 Physi

7、cians 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 monthsadjusted-dose VKA therapy (INR 2.0-3.0) plus si

8、ngle 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 Ph

9、ysicians Evidence-Based Clinical Practice Guidelines For patients with AF at intermediate to high risk of stroke After the first 12 monthsantithrombotic therapy is suggested as for patients with AF and stable coronary artery diseaseAntithrombotic Therapy for Atrial Fibrillation Antithrombotic Therap

10、y 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-e

11、luting 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

12、 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

13、suggested as for patients with AF and stable coronary artery diseaseAntithrombotic 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 AFpatients with no

14、nvalvular 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 greater2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial FibrillationFor patie

15、nts with nonvalvular AFFor 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 Manage

16、ment of Patients With Atrial Fibrillationpatients with AF undergoing percutaneous patients with AF undergoing percutaneous coronary interventioncoronary intervention bare-metal stents may be considered to minimize the required duration of dual antiplatelet therapy Following coronary revascularizatio

17、n (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

18、FibrillationWOESTWOEST試驗試驗 比較了華法林、氯吡格雷加或不加阿司匹林的雙聯(lián)與三聯(lián)治療 結果顯示華法林加氯吡格雷的雙聯(lián)治療 出血風險更低（p0.001）， 1年次要臨床終點（包括死亡、心肌梗死、卒中）發(fā)生率降低（p=0.025） 血栓栓塞風險并不增加 指南對這種抗栓方案更為推崇2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation特殊情況的抗栓治療特殊情況的抗栓治療缺血性腦卒中腦出血轉(zhuǎn)化顱內(nèi)出血房顫合并冠心病圍手術期管理缺血性腦血管疾病患者抗栓治療缺血性腦血管疾病

19、患者抗栓治療缺血性腦血管疾病患者抗栓治療圍手術期管理圍手術期管理 圍手術期的抗血栓形成治療必須評估繼續(xù)用藥所致的出血風險停藥所致的血栓栓塞風險Summary of evidence-based guideline: Periprocedural management of antithrombotic medications in patients with ischemic cerebrovascular disease, Neurology 80 May 28, 2013缺血性腦血管疾病患者抗栓治療缺血性腦血管疾病患者抗栓治療圍手術期管理圍手術期管理 暫停抗栓藥物的血栓栓塞風險？ 繼續(xù)使用

20、抗栓藥物的圍手術期出血風險？ 如暫停口服抗凝藥，需要過渡性治療嗎？ 如果停用抗栓藥物，該停多長時間？Summary of evidence-based guideline: Periprocedural management of antithrombotic medications in patients with ischemic cerebrovascular disease, Neurology 80 May 28, 2013暫停抗血小板藥物暫?？寡“逅幬锼卵ㄋㄈ娘L險所致血栓栓塞的風險 one Class I study1 and 2 Class II studies 暫停阿司

21、匹林很可能增加腦卒中或短暫性腦缺血發(fā)作風險發(fā)生腦卒中風險與阿司匹林停止時間長短相關停藥2周的相對危險度（RR）為1.97停藥4周的比值比（OR）為3.4停藥5月的相對危險度（RR）為1.40Summary of evidence-based guideline: Periprocedural management of antithrombotic medications in patients with ischemic cerebrovascular disease, Neurology 80 May 28, 2013暫?？鼓幬锼卵ㄋㄈL險暫?？鼓幬锼卵ㄋㄈL險 不同抗凝適應癥

22、，停用抗凝藥所致血栓栓塞風險各異。 繼續(xù)使用華法林和停用華法林（有或沒有圍手術期肝素過渡性治療）條件下血栓栓塞的風險，尚缺乏大樣本的研究。 停用華法林超過7天，導致血栓栓塞的風險高達(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中華醫(yī)學會心血管病學分

23、會,中華心血管病雜志編輯委員會.中華心血管病雜志,2013.183-194.如暫?？诜鼓?，需要過渡性治療嗎？如暫?？诜鼓?，需要過渡性治療嗎？ 沒有足夠證據(jù)肝素過渡性治療減少血栓栓塞事件沒有足夠證據(jù)肝素過渡性治療減少血栓栓塞事件 大多數(shù)研究提示肝素過渡性治療可能大多數(shù)研究提示肝素過渡性治療可能增加圍手術期出血風險增加圍手術期出血風險。2個一級證據(jù)、個一級證據(jù)、1個二級證據(jù)、個二級證據(jù)、1個三級證據(jù)的臨床研究，肝素過渡性治療個三級證據(jù)的臨床研究，肝素過渡性治療可增加出血風險可增加出血風險另另1個一級證據(jù)的臨床研究，沒有實質(zhì)性地增加風險。個一級證據(jù)的臨床研究，沒有實質(zhì)性地增加風險。 也沒有足

24、夠證據(jù)發(fā)現(xiàn)也沒有足夠證據(jù)發(fā)現(xiàn)“繼續(xù)服用口服抗凝藥與肝素過渡性治療間血栓栓塞風繼續(xù)服用口服抗凝藥與肝素過渡性治療間血栓栓塞風險差別險差別” 另有另有1個一級證據(jù)臨床研究發(fā)現(xiàn)，牙科手術，使用低分子肝素過渡性治療與繼個一級證據(jù)臨床研究發(fā)現(xiàn)，牙科手術，使用低分子肝素過渡性治療與繼續(xù)服用抗凝藥相比，出血風險很可能相似。續(xù)服用抗凝藥相比，出血風險很可能相似。Summary of evidence-based guideline: Periprocedural management of antithrombotic medications in patients with ischemic cerebro

25、vascular disease, Neurology 80 May 28, 2013如果停用抗栓藥物，該停多長時間？如果停用抗栓藥物，該停多長時間？ 尚無足夠的證據(jù)支持任何明確的結論 抗栓作用時間阿司匹林和氯吡格雷預計可達7天單次量的華法林作用時間預計為2-5天 逆轉(zhuǎn)抗栓作用時間，一般推薦抗血小板藥物停止7-10天華法林停止5天也有很多回顧性分析，提示停藥時間可更短。Summary of evidence-based guideline: Periprocedural management of antithrombotic medications in patients with isch

26、emic cerebrovascular disease, Neurology 80 May 28, 2013推 薦 牙科操作，繼續(xù)使用阿司匹林，很可能（ highly unlikely ）不增加臨床意義的出血性并發(fā)癥。 缺血性腦卒中患者接受牙科手術時應常規(guī)地繼續(xù)服用阿司匹林(Level A)。Summary of evidence-based guideline: Periprocedural management of antithrombotic medications in patients with ischemic cerebrovascular disease, Neurolog

27、y 80 May 28, 2013 推 薦 繼續(xù)使用阿司匹林可能（probably）不增加臨床意義的出血性并發(fā)癥 眼部麻醉、白內(nèi)障手術、皮膚科小手術和操作、經(jīng)直腸超聲引導下前列腺穿刺、腰穿/硬膜外操作、腕管手術(Level B) 鑒于很小臨床意義出血風險 腦卒中患者接受上述操作時也許應該繼續(xù)使用阿司匹林(Level B)。Summary of evidence-based guideline: Periprocedural management of antithrombotic medications in patients with ischemic cerebrovascular dis

28、ease, Neurology 80 May 28, 2013推薦 繼續(xù)使用阿司匹林可能（might ）不增加臨床意義出血并發(fā)癥 玻璃體視網(wǎng)膜手術、肌電圖、經(jīng)支氣管鏡肺活檢、腸鏡檢查、息肉切除術、胃鏡檢查和活檢、括約肌切開術、腹部超聲引導下活檢 較弱證據(jù)支持較小臨床意義出血風險 高危血栓栓塞風險腦卒中病人接受上述操作時可能應該繼續(xù)使用阿司匹林(Level C)。Summary of evidence-based guideline: Periprocedural management of antithrombotic medications in patients with ischemic

29、 cerebrovascular disease, Neurology 80 May 28, 2013 推 薦 雖然出血性不良事件罕見 經(jīng)尿道前列腺切除術，繼續(xù)使用阿司匹林增加臨床意義出血風險沒有達統(tǒng)計學差異 (Level U).Summary of evidence-based guideline: Periprocedural management of antithrombotic medications in patients with ischemic cerebrovascular disease, Neurology 80 May 28, 2013推 薦 髖部骨科手術 繼續(xù)服用阿

30、司匹林很可能（probably）增加出血風險(Level B). Summary of evidence-based guideline: Periprocedural management of antithrombotic medications in patients with ischemic cerebrovascular disease, Neurology 80 May 28, 2013推 薦 牙科操作，繼續(xù)使用華法林很可能（highly unlikely）不增加臨床意義的出血性并發(fā)癥(Level A). 鑒于出血風險小 缺血性腦卒中病人接受牙科操作時應常規(guī)繼續(xù)使用華法林(Lev

31、el A).Summary of evidence-based guideline: Periprocedural management of antithrombotic medications in patients with ischemic cerebrovascular disease, Neurology 80 May 28, 2013推 薦 皮膚科操作，繼續(xù)使用華法林僅輕微(1.2%)增加出血風險(Level B) 皮膚科皮膚操作，也許應繼續(xù)使用華法林(Level B).Summary of evidence-based guideline: Periprocedural man

32、agement of antithrombotic medications in patients with ischemic cerebrovascular disease, Neurology 80 May 28, 2013推 薦 眼科麻醉，繼續(xù)使用華法林很可能（probably）不增加臨床意義出血風險(Level B), 眼科麻醉后眼科手術，雖然出血性不良事件罕見 眼科手術出血風險研究仍得不出“華法林影響臨床意義出血風險”的統(tǒng)計意義 沒有足夠證據(jù)支持眼科手術時需停用華法林(Level U).Summary of evidence-based guideline: Periprocedur

33、al management of antithrombotic medications in patients with ischemic cerebrovascular disease, Neurology 80 May 28, 2013推 薦 肌電圖、前列腺手術、腹股溝疝修補術、大隱靜脈消融手術 華法林可能（might）不增加臨床意義出血 接受上述手術或操作時可能應繼續(xù)使用華法林(Level C).Summary of evidence-based guideline: Periprocedural management of antithrombotic medications in p

34、atients with ischemic cerebrovascular disease, Neurology 80 May 28, 2013For 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 the

35、rapy, 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 nonvalvular AFFor patients with nonva