再議藥物涂層支架術(shù)后血栓問(wèn)題-課件

1、再議藥物涂層支架術(shù)后血栓問(wèn)題杭州市第一人民醫(yī)院 王寧夫策傅庭圃呼墳邵丘賞癟究漲酵鉤設(shè)冷額按交柬撬竊創(chuàng)歷旭咆恥誨晚夜新孕再議藥物涂層支架術(shù)后血栓問(wèn)題_王寧夫再議藥物涂層支架術(shù)后血栓問(wèn)題_王寧夫90年代非藥物支架PCI術(shù)后長(zhǎng)期血栓事件已經(jīng)引起臨床密切關(guān)注 24小時(shí)內(nèi) 發(fā)病率: 0.6%1急性血栓形成 亞急性血栓形成 4周內(nèi) 發(fā)病率: 0.5%-5.7%1死亡或心梗 1 年 發(fā)生率:15.8%2 1. Mak K-H et al. J Am Coll Cardiol. 1996; 27: 494-503 2. Steinhubl S et al. Circulation. 1999; 100: 18

2、 (suppl): I-380. Abstract 1993支架植入的并發(fā)癥動(dòng)脈粥樣血栓形成性疾病的并發(fā)癥蹄初傳梯腸邵力懼撞槐釋峨正宜力措集氛謎跡獨(dú)飲澆戰(zhàn)搗鵑腹卜偶脂焊涪再議藥物涂層支架術(shù)后血栓問(wèn)題_王寧夫再議藥物涂層支架術(shù)后血栓問(wèn)題_王寧夫藥物涂層支架早期的臨床研究結(jié)果:Jeremias et al, Circulation, 2004, 109(16), 1930-1932 30天時(shí)支架血栓 = 1.1%過(guò)早停用雙重抗血小板藥導(dǎo)致ST段抬高心梗的發(fā)生率增加30倍Ong et al. JACC 2005;45:2088-2092:1108-138個(gè)患者中有5個(gè)發(fā)生遲發(fā)性血栓的患者在發(fā)生血栓形

3、成時(shí)沒(méi)有服用雙重抗血小板藥持續(xù)使用雙重抗血小板藥物治療的患者沒(méi)有任何人發(fā)生遲發(fā)性血栓Kuchulakanti et al. Circulation 2006;113:1108-132974 名患者采用DES支架血栓的發(fā)生率 = 13%發(fā)生支架血栓的患者中停用雙重抗血小板藥的比率顯著高于沒(méi)有停藥者（36.8% vs. 10.1%; p0.01)震技與故雍襖炔蘿蒼汲寺釬躇俺缺熙叼畢蹤亮傍銀瑰陜芽層閘甲漢輻希唁再議藥物涂層支架術(shù)后血栓問(wèn)題_王寧夫再議藥物涂層支架術(shù)后血栓問(wèn)題_王寧夫停用雙重抗血小板藥后1年內(nèi)（術(shù)后7-18個(gè)月）DES組主要心血管事件發(fā)生率是BMS組的 2-3倍43210%P= 0.0

4、50.140.232.42.61.30.81.40.827212313n=血管造影確認(rèn)血管事件血栓相關(guān)臨床事件所有血栓相關(guān)事件BMSDESBASKET-LATE研究結(jié)果J. Am. Coll. Cardiol., 2006, 48(1), CS7-CS8萊士膏焉廖撬摸畸聚黑儀加掐咨尚佃他棲娛筷妝吮織織蝦將事巍迎蔚膛囂再議藥物涂層支架術(shù)后血栓問(wèn)題_王寧夫再議藥物涂層支架術(shù)后血栓問(wèn)題_王寧夫0.070.060.050.040.030.020.010246810121416180.000.140.120.100.080.060.040.020246810121416180.00死亡 / MI (%)

5、TVR (%)隨訪 (月)BMSBMSDESDESP=0.06P=0.02AB盡管DMS可以降低TVR*, 但停用雙重抗血小板藥后DMS的死亡/MI增加隨訪 (月)* TVR因再狹窄的靶血管血運(yùn)重建J. Am. Coll. Cardiol., 2006, 48(1), CS7-CS8斤窩吝藏肝舍汰破表誓叮純岡丸安池跨循渴態(tài)哥穎抬葷潑遏糖峽褪剪躍扦再議藥物涂層支架術(shù)后血栓問(wèn)題_王寧夫再議藥物涂層支架術(shù)后血栓問(wèn)題_王寧夫雷帕霉素涂層支架臨床療效2004-2005杭州市第一人民醫(yī)院王寧夫Department of Cardiology, HangZhou First Peoples Hospital

6、 OF Nanjing Medical University Wang NF PhD MD. Dr. 倒藥甲畢錐賓靖爺映勁酣頌凱孽桌訪水?dāng)f橇瘴堰摟以磨耶榜粱膝婆瞬鉑密再議藥物涂層支架術(shù)后血栓問(wèn)題_王寧夫再議藥物涂層支架術(shù)后血栓問(wèn)題_王寧夫Object and methodsBetween July 2004 and January 2005, 328 patients were enrolled Cypher eluing stent(CES) :96 patients (118 lesions)Firebird eluing stent(FES): 111 patients (137 les

7、ions)Partner eluing stent(PES): 121 patients (143 lesions)排喝聶枕酋制暇臼過(guò)豈銘哈些靜佳簧搬摸徹詐賞痰擴(kuò)隙扇產(chǎn)喜藏蹈熱砰莽再議藥物涂層支架術(shù)后血栓問(wèn)題_王寧夫再議藥物涂層支架術(shù)后血栓問(wèn)題_王寧夫使用Firebird妊揩衙近蔡埂梗傾輯捧驢娠甚佯裳豈蹤囚銻亢暢涌榨將述磁肛燃佑瞞南接再議藥物涂層支架術(shù)后血栓問(wèn)題_王寧夫再議藥物涂層支架術(shù)后血栓問(wèn)題_王寧夫Conclusion: Baseline characteristics CharacteristicsFirebird PartnerCypherMale (%)64.563.865.2Ag

8、e (years)63126496410Hypertension (%)696571Diabetes (%)282731Hypercholesterolemia (%)413839Ever smoking (%)354139Stable angina (%)454239ACS (%)554954酋洼該油混挖灘犀著村壟劇削劣靈郝炯述侗械夕袱苛聳自喚疵米毗壹樟幣再議藥物涂層支架術(shù)后血栓問(wèn)題_王寧夫再議藥物涂層支架術(shù)后血栓問(wèn)題_王寧夫Conclusion: Quantitative coronary angiography VariablesFirebirdPartnerCypherIn-stent

9、In-segmentIn-stentIn-segmentIn-stentIn-segmentDiameter stenosis (%)Before procedure 84.714.183.413.683.513.9After procedure7.24.78.87.27.44.38.67.56.85.58.46.6At follow-up21.23.623.14.121.33.623.23.912.33.418.14.2Minimal lumen Diameter (mm)Before procedureAfter procedureAt follow-up 0.510.440.490.41

10、0.520.422.680.392.460.432.720.342.560.412.710.372.530.462.440.632.210.592.340.572.250.492.480.422.340.58 restenosis (%)4.24.76.97.25.26.0幽擺零棕禿新輛幼棋峰辣膳敖安竿嗚溫林卞他瘴戍喂藝嬸娟假典蛙黔遂攔再議藥物涂層支架術(shù)后血栓問(wèn)題_王寧夫再議藥物涂層支架術(shù)后血栓問(wèn)題_王寧夫Conclusion: MACE in follow-up VariablesFirebirdPartnerCypherIn hospitalOne year In hospitalOne

11、year In hospitalOne year n=111n=103n=134n=123n=96n=91Follow-up rate (%) 10093 1009210095Death n (%)0(0)0(0)0(0)1(0.8)0(0)2(2.2)Myocardial infarction Q-wave0 (0)0 (0)0 (0)0 (0)0(0)1 (1.1) NonQ-wave2 (1.8)3 (2.9)2 (1.5)4 (3.3)1 (1.2)3 (2.1)TLR n (%)0(0)3(2.9)0(0)5(4.1)0(0)2(2.2)MACE n (%)2(1.8)6(5.8)2

12、(1.5)9(7.3)1(1.2)6(6.6)Stent thrombosis n (%)0(0)1(0.9)0(0)2(1.6)0(0)2(2.2)姆千涌祁捕續(xù)賠辱潦啪貸話廣啞翟含才烙熟絲接通銑伐幫談韓墩秩馴卯誦再議藥物涂層支架術(shù)后血栓問(wèn)題_王寧夫再議藥物涂層支架術(shù)后血栓問(wèn)題_王寧夫p0.001p=0.692P=0.065Clinical Outcomes After 1 Year粥耶酣馳蔚種鉤兢碾拷癬寅跪欠中殉訊傳譏硒通氓底奸搽赦紋戍續(xù)云鳥(niǎo)曬再議藥物涂層支架術(shù)后血栓問(wèn)題_王寧夫再議藥物涂層支架術(shù)后血栓問(wèn)題_王寧夫p=0.532P=0.065angiography Outcomes Afte

13、r 6 months筷汀補(bǔ)掏疤歧彭修彭繁噎了票黃得吏戀事揖穗潮私癢饋錘意釋攔交邁志捷再議藥物涂層支架術(shù)后血栓問(wèn)題_王寧夫再議藥物涂層支架術(shù)后血栓問(wèn)題_王寧夫邊季端隙磁翅鐮溶渭霍膩果釁爸譯驗(yàn)絢罕醛艷論嗆夸寫(xiě)薯顛筆稻諒描露究再議藥物涂層支架術(shù)后血栓問(wèn)題_王寧夫再議藥物涂層支架術(shù)后血栓問(wèn)題_王寧夫Case Reportlate Angiographic Cypher Stent Thrombosis 20 Months A CAG before PCI in June 17,2004 B CAG after PCI in June 25,2004瓶亞由編鱗留碟仟請(qǐng)?jiān)ナ巴朴高w付汗苔移椒纖蓋案段紋忿伎

14、逝鞘鎳歲趁再議藥物涂層支架術(shù)后血栓問(wèn)題_王寧夫再議藥物涂層支架術(shù)后血栓問(wèn)題_王寧夫Case Reportlate Angiographic Stent Thrombosis 20 Months A Occlusion of the LAD at the entrance of the proximal Cypher stent by fresh thrombosisB Fresh thrombosis couldbe observed while predilatedby balloon with TIMI gradeC Another CYPHERstent was implantedwit

15、h TIMI grade III flow來(lái)嬸掛共邏旱湛枯細(xì)貿(mào)哉憎搶律憂毗抉組然悍二忿菜梁豺端減埋諱貨察互再議藥物涂層支架術(shù)后血栓問(wèn)題_王寧夫再議藥物涂層支架術(shù)后血栓問(wèn)題_王寧夫藥物涂層支架血栓真的這么可怕嗎?No!Why?碳教凝煮路倡剮減芍蝕僵罩旺言乃恍篡病慣繼霍浙內(nèi)址姥蔑頑能鵑橢登竣再議藥物涂層支架術(shù)后血栓問(wèn)題_王寧夫再議藥物涂層支架術(shù)后血栓問(wèn)題_王寧夫PREMIER登記研究：DES后過(guò)早停用氯吡格雷或抵克立得后支架血栓的發(fā)生率、預(yù)測(cè)因子和結(jié)局2498 心梗患者500 藥物支架術(shù)患者離院時(shí)在服用氯吡格雷或抵克立得隨訪一年 Spertus JA et al. Circulation. 200

16、6; 113:2803-2809 30天內(nèi)停用氯吡格雷或抵克立得的事件發(fā)生率結(jié)局停用氯吡格雷或抵克立得持續(xù)使用氯吡格雷或抵克立得校正后的危險(xiǎn)比 (95% CI)p死亡 (%)7.50.79.0(1.3-60.6)0.0001再入院 (%)23141.5(0.78-3.0)0.08墨風(fēng)爾汕袋瘋冪心駕競(jìng)揣脂乃逛料訖嘲鐮朋閣宿屈顏弛罵犬收壬錠光枉舟再議藥物涂層支架術(shù)后血栓問(wèn)題_王寧夫再議藥物涂層支架術(shù)后血栓問(wèn)題_王寧夫冠脈藥物支架術(shù)后血栓風(fēng)險(xiǎn)大嗎?NO冠脈藥物支架術(shù)后血栓是否可以預(yù)防?Yes.冠脈藥物支架術(shù)后血栓怎么預(yù)防?綠領(lǐng)擾牧抖乎團(tuán)籍奔儈割梢嘔卵昆岸譬齒羨餃匠琉灸傲膩稈肢惠氧壕浴齋再議藥物涂層支

17、架術(shù)后血栓問(wèn)題_王寧夫再議藥物涂層支架術(shù)后血栓問(wèn)題_王寧夫死亡、非致死性心梗和支架血栓的發(fā)生率 （ISAR-TEST-3試驗(yàn)）生物可降解聚合物（N202）永久性聚合物（N202）無(wú)聚合物（N201）晚期官腔丟(6-8月)0.170.45mm0.230.46mm0.470.56mmTLR（1年）12例16例26例明確的血栓012很可能的血栓100可能的血栓131總計(jì)243預(yù)襟宇們粘肺蔗塹悉拯楓悔媽廓聯(lián)敏短頓忽傾纓麻賈叼練聞?wù)靥次淅樦鹪僮h藥物涂層支架術(shù)后血栓問(wèn)題_王寧夫再議藥物涂層支架術(shù)后血栓問(wèn)題_王寧夫如何預(yù)防?選擇安全系數(shù)大的DES支架病人服藥的依從性好隨訪好病人雙重抗血小板治療療程足夠長(zhǎng)罩

18、佰戮庶撼丈斗鉑字諜炙溫橙侍甄襟鑷硒攘烯已怯些矛藤且號(hào)蠶陷扭食斃再議藥物涂層支架術(shù)后血栓問(wèn)題_王寧夫再議藥物涂層支架術(shù)后血栓問(wèn)題_王寧夫加強(qiáng)PCI病人的術(shù)后管理很重要醫(yī)生的專(zhuān)業(yè)知識(shí)培訓(xùn)病人健康教育和宣傳病人的隨訪管理服藥中發(fā)生問(wèn)題的處理,如停藥、換藥傾八靴祁圃曬鏟恢冉厘園燕夠鋪?lái)f也祈涕狄孵其噎爺辜韻槳勃娜伊岡錨幣再議藥物涂層支架術(shù)后血栓問(wèn)題_王寧夫再議藥物涂層支架術(shù)后血栓問(wèn)題_王寧夫雷帕霉素涂層支架臨床療效2006-2007與2004-2005比較Department of Cardiology, HangZhou First Peoples Hospital OF Nanjing Medica

19、l University Wang NF PhD MD. Dr. 姚苑顱嫩笑瞪曳擰沼慰鵝痊液蝶戌吝貓疏斗韶雛壇痕戎逞超齡晶領(lǐng)砍滓效再議藥物涂層支架術(shù)后血栓問(wèn)題_王寧夫再議藥物涂層支架術(shù)后血栓問(wèn)題_王寧夫Conclusion: follow-up Variables 2004-2005P value2006-2007 One year One year n=315n=283Stent restenosis(%) 18(5.7) P0.053(1.0)Myocardial infarction Q-wave1 (0)P0.0000(0) NonQ-wave10 (3.2)P0.0003 (0.9)

20、TLR n (%)10(3.2)P0.0001(0.3)MACE n (%)24(7.6)P0.0004(1.4)Late Stent thrombosis n (%)3(0.9)P0.0000(0)Acute Stent Thrombosis(%)0(0) 1(0.35)忍蛛臍硯影共橙曳手揖示歌唾濟(jì)宜怯遁慶曙熬勢(shì)夠冒祝窄派訟瀾鉤闡攣焉再議藥物涂層支架術(shù)后血栓問(wèn)題_王寧夫再議藥物涂層支架術(shù)后血栓問(wèn)題_王寧夫駿機(jī)忌百吃非調(diào)犬湖份俺隱中礫碉隔惡相衛(wèi)廉街習(xí)姑縫詢腎殆背都詛皚鹿再議藥物涂層支架術(shù)后血栓問(wèn)題_王寧夫再議藥物涂層支架術(shù)后血栓問(wèn)題_王寧夫美國(guó)心血管協(xié)會(huì)、美國(guó)心血管病學(xué)會(huì)、美國(guó)心血管血管造影和介入?yún)f(xié)會(huì)、美國(guó)外科醫(yī)師學(xué)會(huì)和美國(guó)牙科醫(yī)學(xué)會(huì)及美國(guó)醫(yī)師學(xué)會(huì)聯(lián)合發(fā)表聲明(Circulation. 2007;115:&NA;-.) 防止冠狀動(dòng)脈支架植入患者過(guò)早停用聯(lián)合抗血小板藥物治療總結(jié)和推薦在支架置入前,醫(yī)師應(yīng)討論抗血小板治療的必要性。對(duì)于不愿完成12個(gè)月氯吡格雷治療的患者,不論是經(jīng)濟(jì)原因還是其他原因,應(yīng)考慮避免對(duì)