阿司匹林精準(zhǔn)治療指引

1、阿司匹林的精準(zhǔn)治療 20150425阿司匹林單藥，用于心血管疾病的二級預(yù)防；阿司匹林與氯口比格雷或替格瑞洛聯(lián)用，用于預(yù)防心腦血管支架血栓的發(fā)生等。3Ts Guidance on Prescribing Oral Antiplatelet Drugs用器 note pre&cnbers in acute settings should read this in conjunction with A-cute Trust PPCI &Chest Pain pnotocals.Secondary preventionafter STEMI with PCIAspirin 75mgdaily (iGn

2、jg- term) andIBOmgstat then 90mg twice daiilv (for 12 moflthsj.* If patient i intolerant 力皿 has a stent ttiromboEis whilst an ticacretor. cmwliter mplric 75mg dail I Ikang-term aod themif under 60 kg or ver 75 years 由4的件力 upto 12 monthE；),. hot only &n the iadvke a 8力瞰 Cardiologist. if patient hasco

3、ntraind ications to, is intoleont ofrhoisa stent thrombosis whilst on prasufrel ieek the Advice 9 a Consultant Cardial agist.Setondary preventionafter STEMI without PCI用s犯irin 73nle 山抑(tong-term) -d7nig daily frat least 2-6 days and cartEider for up g IN rrtohths).if Aspirin isc&nftra-iridicatecl 5

4、not tolerated, clopidogrel 75mg daily I lonig=term)* Aspirin 75mg daijly nEtgnrn) -dySme dei帆(for 12 morYths).*lf Aspinn is contra-in-d icatedl or not toleratedr clopidoErel 75 mg daily (long-term )*. lf patient is intolerant of or known to be resisUnt t& clopidQgrdr aspirin 了5mg daily (tonfi-term)

5、and1: c-i l0mg ?tat then 90ml!wk:e daily (for 12 moHiths1.If patient is intolerant of ticafirtlor, consider 的 in 75 mg dailr (long-teiro j ;and unlicensed use ofthen lOmg (Smg if under 60 kf or Over 75 ve&rS old dldilh/ (for 1.2 months but orulvon the advice of a Consultant Cardiologist.if patient i

6、s intofera nt of or kncv/n to be ristant to clopidcfre4, aspiirin 7Smg dail I lung亡erm andISOrtif stdl then TOn 唱 twice daily Ifor at lea5t 2 days and cortsicterfur upto 12 months).If patient is intofera nt o-f tl皿eloc corisbder ”而 in 7Smg daily long-term) and unlicensedOOntg 優(yōu)成then iani (Snr if und

7、ergo leg or over 7S years old daity (for at l*Mt 28 dg and ewiider for up 3 12 months) but C4nly on the advice of a Consultant QMi 白 IcfiiftSecondary prevention aftr NSTEMI with PCIAspirin 7Smg daily 1110r1Mliterm) 3Hd75me ddiiyqfix12 inwm 5).*If Aspirin 社 contrarjndicated or nottolerdtecL 工 k9汕咱 M

8、75mg daily (lang-tenn|i,aIf patient, htotenm ct h a stent thrombasis whi 1st on oris known to be resistant todo儀次工3r ri- |jii inddilv(long-term) and60me stat then LOm： (5me if under 日電 qt ger 75 ear$ old daily for 12 months|lt. if patient Ms contraindlcstions tojs- int必曰nt of 更 hmw a sbe-nt thrombos

9、is wtiiibt. on pf?sugrel,解“M 乃me daily long-term) andISOniE stat then 90hie twice daily (for 12 months).Secondary preverntiori afterUnttdMe Angina & NSTEMIwithout PCIReview Date; March 2017,Written by GWH Form uhry team.,Approved by FWG; M3Mh 2014,3Ts Guidance on Prescribing Oral Antiplatelet DrugsP

10、lease note prescribers in acute settings should read this in conjunction with Acute Trust PPCI &Chest Pain protocols.Secondary preventionafter coronary arterybypass graftSecondary prevention after ischaemic strokeSecondary prevention in peripheral artery disease or multi-Secondary preventionafter tr

11、ansientischaemic attackPrimary preventionDifferent tertiary centres have different protocols for the ue of oral anti platelet drugs post- CABG.Please see correspondence from your patients Cardiovascular Surgeon for further information.Clopidogrel 75mg d-aily (long-tprm)If Clopidogrel is contraindica

12、ted or not tolerated, seek the specialist advice of a Consultant Vascular Surgeon or Consultant Cardiologist.Aspirin 300mg daily (for 14 days or until discharge) then Clopidogrel 75n daily (long-term).If Clopidogrel is contraindicated or not tolerated. Aspirin 300mg daily (for 14 days or until dtsch

13、arge) then Aspirin 75mg daily (long-term) & Dipyviddniole MR 200mg twke daily (long-term).If Clopidogrel and Aspirin are contraindicated or not tolerated. Dipyridamole MR 200mg twke daily (long-term)*.Aspirin 300mg stat then Clopidogrel 7sms doily (long-term)#.If Clopidogrel is contraindicated or no

14、t tolerated. Aspirin 300mg stat 由 en Aspirin 75mg daily (long-term) and Dipyridamole MR 200mg twice daily (long-term).If Clopidogrel and Aspirin are contraindicated or not tolerated. Dipyridamole MR 200mg twice daily (long-term)*.Primary prevention with low dose asoirin is not routinely recommendedl

15、ow dose aspinn may be appropriate in some high- risk patients and so may be prescribed on on individual basts as follows:Aspirin 75rng daily (long-term).If Aspirin is contraindicated or not tolerated, Clopidogrel 75mg daily (long-term)*.Use with cdution in patients wtth uncontrolled hypertension and

16、 stop if patient develops dyspepsia.Written by GWH Formulary team.Approved by FWG: March 2014.Review Date: March 2017.3Ts Guidance on Prescribing Oral Antiplatelet DrugsPlease note prescribers in acute settings should read this in conjunction with Acute Trust PPCI &Chest Pain protocols.Antiplatelet

17、therapy in patients with an indication for anticoagulationConcomitant use of oral antiplatelet drugs with antkoagulants should ONLY be undertaken on the advice of a Cardiology, Stroke or Haematology Consultant. NICE Clinical Guideline 172: Myocardial Infarction - Secondary Prevention makes the follo

18、wing recommendations on the use of oral antiplatelet drugs in patients who have had an Ml but also have an indication for anticoagulation:When considering treatment for patients who have an indication for anticoagulation, take into account bleeding risk, thromboembolic risk, and cardiovascular risk.

19、Unless there is a high risk of bleeding, continue anticoagulation and add aspirin in people who have:had their Ml managed medically, OR一 undergone balloon angioplasty, ORundergone CABG surgery.Continue anticoagulation and add dopidogrel in people who have undergone PCI with bare metal or drug-elutin

20、g stents.Offe- dopidogrel with warfarin to people with a sensitivity to aspirin.Do hOT routinely offer warfarin in combination with prasugrel or ticagrelor.After 12 months since the Ml, continue anticoagulation and review the need for ongoing antiplatelet therapy, taking into account the indicatton

21、for anticoagulatlon, thromboembolic risk, bleeding risk, cardiovascular risk and the persons wishes.Do NOT add a new oral anticoagulant (rivaroxaban, apixaban or dabigatran) in combination with dual antiplatelet therapyCon If Cardiology clink letters will jdwli&e accordingly,昌印iriri intolerance is d

22、efined as proven hyperARriAitiyity to aspirin ar 日 history of severe indigestion caused by low dose aspirin, persisting after We use of a PPI. Where aspirin or clopidogrel are indicated! and the patient has Gl symptoms, consider adding a PPL If a PPI iis. required with clopidogrL prescribe lansopraz

23、ole |口pantoprazole if lansoprazale is cantraindicated ar not tolerated) omepr5iole and esonneprawle signifiufitly reduce the antiplatelet effect of clopidogrel.tclopidofireli intolerance is na匕 and switching its only expected to b-e necessarY for approx. 5 patients per year.ClCFpidogrel 1sl not lice

24、nsed for the prevention of dccluslve Vehicular evcnB dn tia patients and Hsuse in this 的3y is c*ut&id 0f the recommendations of NICETAZIO but is recommended by Avan, Glmc史文ershk匕 Wiltshire and Samerset Cardiac and Stroke Network (AGWSCSN)1.ReferencesNICE Tedinofogy AppQisal TA210. Vascular disease c

25、lopidogrel & dipyridaimol已一 ， Decemtngr 2010.AGWS Cadiac and Stroke Network Amti-platelet Management Post- Stroke and TIA Smidelines October 2011.httD：/www,3gwscs. n ha山k/fil笛/mnti -tIM0mMsmaEgmnt-posVstrolkgTTCI -tig agwsg- n電tw口k-Euid舊hrvaspdf3Ts Formuilary Working Group statent on th型 use of gene

26、ric dopidogrel. November 2009.htt 口:弓/RD3rtnnnt，Phmrnmcv/GLiid0lin0，docum0nts12 a03doffrRl-T5rrKHnt irz j!0npn-NOTO9,KH:盤NICE TechnoHogy Appraisal TAISJ- Acute corona ry syndrome 三 Prasugrel.上 .OctolH! r 20094NICE TechnoHogy AppraisalA23a Acute rorona ry syndrorriies - Ticarelor. October 2011.NJCE C

27、linical Guideline CG172. Myocardial Infairrtion-Siecondiary Prevent2n. November 2013.httn:/wwwmicewrE，uk/in3mHgflia/IMi14302/6i5G9iy65B96jKtfWritten by GWM Formulary team. Approved by FWG: March 2014. Review Date: Mairh 2017,一、阿司匹林基因位點：1、GPIIIaPlA1/A2PEAR1PTGS1GP1BAGSTP1LTC4S-k贅生.*、 W 口 LTC4S: AC CC

28、基因型，使用阿司匹林發(fā)生尊麻疹的風(fēng)險較高。建議不用阿司匹林。GSTP1 GG和AG型，使用阿司匹林，消化道出血風(fēng)險較高，建議不用阿司匹林。3、易出血人群，消化系統(tǒng)潰瘍史，活動性消化性潰瘍，肝腎功能衰竭，痛風(fēng)患者禁用阿司匹林4、妊娠期后三個月禁用。5、同時使用其他非留體抗炎藥物，激素類藥物，大劑量維生素C會加重粘膜刺激造成出血等不良反應(yīng)。6、服藥期間禁止飲酒或攝入酒精。三、出具個體化治療報告時，還應(yīng)注意：阿司匹林個體化治療，在臨床常面臨以下情況：報告結(jié)尾，還應(yīng)寫明以下兩點：應(yīng)關(guān)注藥物相互作用等因素的影響。本結(jié)論僅根據(jù)基因檢測結(jié)果和循證醫(yī)學(xué)證據(jù)得出，具體用藥方案，尚需結(jié)合患者血小板反應(yīng)等具體情況綜

29、合判斷。四、阿司匹林單藥個體化治療建議（心血管疾病二級預(yù)防）：在無阿司匹林抵抗的前提下，可使用常規(guī)劑量阿司匹林治療，但需高度關(guān)注出血風(fēng)險。尤其是消化系統(tǒng)出血 （應(yīng)根據(jù)既往史、GSTP1S因及臨床反應(yīng)判斷）。如存在出血高危因素（如既往出血史、 GSTP1S因的GG口AGS1、嚴(yán)重貧血、血小板數(shù)量和功能降低、低白蛋白血癥或低凝血因子血癥者），則：（1）換用其他抗血小板藥物，如氯口比格雷（但需關(guān)注不同基因型對氯口比格雷藥效的影響），或換 用雙喀達(dá)莫；（2）聯(lián)合使用增強(qiáng)胃黏膜屏障功能的藥物，如米索前列醇等或使用H2受體阻斷劑如法莫替丁或PPI類藥物（如患者使用氯口比格雷應(yīng)建議使用雷貝拉嘎）。3、上述結(jié)論僅根據(jù)基因檢測結(jié)果和循證醫(yī)學(xué)證據(jù)得出，具體用藥方案，尚需結(jié)合患者血小板反應(yīng)等 具體情況綜合判斷。五、阿司匹林聯(lián)合用藥個體化治療建議（一）如基因未發(fā)生突變，可按正常劑量使用（二）如發(fā)生突變尤其為突變純合型1、GP IIIa PlA2 （T C） C褒因型，行支架術(shù)后，其亞急性