磺達(dá)肝葵鈉解讀

AmericanCollegeofChest

PhysiciansEvidence-Based

ClinicalPracticeGuidelines

(9thEdition)

ACCP9–AboutFondaparinuxAfirst-generationsyntheticanalogoftheantithrombin-bindingpentasaccharideTheprototypeformostofthenewindirectfactorXainhibitorsLicensedforpreventionofVTEinpatientsundergoinghigh-riskorthopedicsurgeryand,insomecountries,ingeneralsurgicalormedicalpatientsAsubstituteforheparinorLMWHforinitialtreatmentofVTELicensedinEuropeandCanada,butnotintheUnitedStates,asanalternativetoheparinorLMWHforthetreatmentofACSThreeofthenewerindirectfactorXainhibitors,idraparinux,idrabiotaparinux,andSR123781A,aresecond-andthird-generationvariants（變異體）offondaparinuxFondaparinuxisgivenatafixeddoseof2.5mgdailyforthromboprophylaxisandforthetreatmentofACSFortreatmentofDVTorpulmonaryembolism5mg:weight<50kg7.5mg:weight50to100kg10mg:weighing>100kg.routinecoagulationmonitoringisnotrecommendedpatientswithmoderaterenalinsufficiency(ie,CrCl

30-50mL/min),thedoseoffondaparinuxshouldbereducedby50%contraindicatedinpatientswithrenalinsufficiency(CrCl<30mL/min)2.1.8—2.1.11房顫患者抗凝的選擇AspirinClopidogrelOralanticoagulation

remarksDabigatranVKAlowrisk（0）IntermediateRisk(1)

UnableforOAhighrisk(≥2)

UnableforOAAFandmitral

stenosisUnableforOADabigatran

150mgbid推薦應(yīng)用：更好的選擇：

PerioperativeManagementserialimagingofth（2C）e

patientstemporaryinterruptionofaVKAbeforesurgerystoppingVKAsapproximately5daysbeforesurgery（1C）BridgingAnticoagulation1.mechanicalheartvalve2.Atrialfibrillation3.HighriskofthromboembolismBridgingAnticoagulationBridginganticoagulationastheadministrationofashort-actinganticoagulantSubcutaneous(SC)LMWHorIVUFH10-to12-dayduringinterruptionofVKAtherapy

PreventionofVTEinHospitalizedAcutelyIllMedicalPatientsserialimagingofthe

acutelyillhospitalizedmedicalpatientsinitialtreatmentwithparenteralanticoagulation（1B）LMWH（1B）

fondaparinux(1B)LDUH（1B）PreventionofVTEinNonorthopedicSurgicalPatientsserialimagingofthegeneralandabdominal-pelvicsurgery

moderateriskforVTE+notathighriskformajorbleedinglow-doseaspirinFondaparinux(2C)LMWH(2B)LDUH(2B)IPC

（2C)2.1PreventionofVTEinOrthopedicSurgeryPatientsInacutePEpatients,whenuseathrombolyticagentInacutePEpatients,whenuseathrombolyticagentTotalHipArthroplasty(THA)orTotalKneeArthroplasty(TKA)

minimum10to14daysLMWHispreferable(2B)LMWH

fondaparinuxapixaban、dabigatran、rivaroxabanlow-doseUH、VKA、aspirin(1B）2.1PreventionofVTEinOrthopedicSurgeryPatientsInacutePEpatients,whenuseathrombolyticagentInacutePEpatients,whenuseathrombolyticagentHipfracturesurgery(HFS)

minimum10to14daysLMWHispreferable(2B)LMWH

FondaparinuxLDUHVKAAspirin(1B）

2.1急性下肢DVT的抗凝方案的選擇serialimagingofthepatientswithacuteDVTofthelegtreatedwithVKAtherapyinitialtreatmentwithparenteralanticoagulation（1B）LMWH（2B）

Fondaparinux(2C)OverUFHLMWHOncedailyAdministrationWiththesamedose（2C）

3.3.1/3.3.2選擇抗凝療法作為長期治療DVTofthelegnocancerDVTofthelegand

cancerVKA>LMWH>dabigatran/rivaroxaban(2C)LMWH>VKA>dabigatran/rivaroxaban(2B)

5.1急性肺栓塞的抗凝方案的選擇serialimagingofthepatientswithacutePEinitialtreatmentwithparenteralanticoagulation（1B）LMWH（2B）

Fondaparinux（2C）OverUFHLMWHOncedailyAdministrationWiththesamedose（2C）總結(jié)預(yù)防深靜脈血栓：

內(nèi)科急重癥+骨科手術(shù)

非骨科手術(shù)，若LDUH與LMWH禁忌，可選用治療靜脈血栓栓塞癥（深靜脈血栓+肺栓塞）證據(jù)級(jí)別2C(LMWH2B)

Thankyou3.1/3.2/3.3AF合并冠心病的抗凝治療

AFstable

coronaryartery

disease

VKAaloneAF(2)+intracoronarystentTripletherapy(bare-metal1m/drug-eluting3-6m)VKA+singleantiplatelet(until12m)

VKAalone(after12m)AF(0-1)+intracoronarystentDuralantiplatelet(until12m)AFwithstable

coronaryartery

disease(after12m)AF(≧1)+ACS+unableintra~stentVKA+singleantiplateletor

Triple(until12m)

VKAalone(after12m)AF(0)+ACS+unableintra~stentDuralantiplatelet(until12m)AFstable

coronaryartery

disease(after12m)ACCP9指南

——非骨科手術(shù)患者的VTE預(yù)防VTE風(fēng)險(xiǎn)分級(jí)VTE發(fā)生率Roger評(píng)分*Caprini評(píng)分*出血風(fēng)險(xiǎn)預(yù)防推薦推薦級(jí)別極低危<0.5%<70—不預(yù)防機(jī)械預(yù)防1B2C低危~1.5%7~101~2—機(jī)械預(yù)防（IPC）2C中危~3.0%>103~4低LMWHLDUH機(jī)械預(yù)防（IPC）2B2B2

C高機(jī)械預(yù)防（IPC）2C高危~6.0%—≥5低LMWHLDUH建議聯(lián)用機(jī)械預(yù)防（ES或IPC）1B1B2C高機(jī)械預(yù)防（IPC）2CCHEST2012;141(2)(Suppl):e227S–e277SIPC：間斷充氣加壓裝置；LDUH：低劑量普通肝素；ES：彈力襪Roger評(píng)分：依據(jù)手術(shù)類型、麻醉評(píng)分、輔助檢查等的風(fēng)險(xiǎn)評(píng)估模型Caprini評(píng)分：依據(jù)年齡、病史、合并疾病等的風(fēng)險(xiǎn)評(píng)估模型DVT深靜脈血栓（DeepVeinThrombosisDVT)，DVT是在某一條深靜脈中出現(xiàn)了血液凝塊，血液的正常流動(dòng)受阻。DVT通常出現(xiàn)在下肢，如骨盆、大腿和小腿，于是把下肢DVT又分為：小腿DVT和髂—股DVT靜脈血栓栓塞癥（VTE）：VTE包括深靜脈血栓形成（DVT）及肺栓塞（PE）Xa因子磷脂Va因子–Xa因子Ca2+內(nèi)源性通路外源性通路凝血酶原凝血酶纖維蛋白原纖維蛋白凝血酶原復(fù)合物啟動(dòng)階段放大階段血小板聚集凝結(jié)Xa因子直接Xa因子抑制劑Chest2012;141;e44S-e88SRiskFactorsforVTEinHospitalizedMedicalPatientsInthePaduaPredictionScoreriskassessmentmodel,highriskofVTEisdefinedbyacumulativescore4points.Inaprospectiveobservationalstudyof1,180medicalinpatients,60.3%ofpatientswerelowriskand39.7%werehighrisk.Amongpatientswhodidnotreceiveprophylaxis,VTEoccurredin11.0%of

patientsvs0.3%oflow-riskpatients(HR,32.0;95%CI,4.1-251.0).Amonghigh-riskpatients,theriskofDVTwas6.7%,nonfatalPE3.9%,andfatalPE0.4%.Table11—[Section2.9,2.10,5.6,9.2]RiskFactorsforBleedingWithandContraindicationstoUseofThrombolytic（溶栓）Therapy(BothSystemicandLocallyAdministered)房顫患者應(yīng)用VKA與雙聯(lián)抗血小板的比較達(dá)比加群較華法林的優(yōu)越性2.1.11RecommendationRegardingDabigatranvsAdjusted-DoseVKATherapy:TheRE-LYtrialshowedthatdabigatran,atthehigherdoseof150mgbid,leadstoreductionsinnonfatalstroke,probablereductionsinall-causemortality,andnoapparentincreaseintheriskofnonfatalmajorextracranialbleedingcomparedwithVKAtherapy(Table9),whereastherewasnoevidencethatdabigatran110mgbidleadstoasignificantreductioninrelevantoutcomescomparedwithVKAtherapy(Table10).IntheUnitedStates,theFoodandDrugAdministration（FDA）approvedtheuseofdabigatranforthepreventionofthromboembolisminpatientswithAFatadoseof150mgbidbutnotatadoseof110mgbid.However,theFoodandDrugAdministrationdidapprove,basedonpharmacokineticconsiderationsratherthandirectevidencefromRCTsinAFpopulations,adoseof75mgbidforpatientswithsevererenalinsufficiency(definedasacreatinineclearance15-30mL/min).3.1PatientsWithAFandStableCoronaryArteryDisease3.1.ForpatientswithAFandstablecoronaryarterydiseaseandwhochooseoralanticoagulation,wesuggestadjusted-doseVKA

therapyalone(targetinternationalnormalizedratio[INR]range,2.0-3.0)ratherthanthecombinationofadjusted-doseVKAtherapyandaspirin(Grade2C).stablecoronaryarterydisease:noacutecoronarysyndromewithinthepreviousyear

4.1PatientsUndergoingElectiveCardioversionofAF（>48h）serialimagingofthepatientswithAFofgreaterthan48horunknowndurationundergoingelectiveelectricalorpharmacologiccardioversionAnticoagulationatleast3weeksbefore

（1B)Anticoagulationatleast4weeksafter(1B)regardlessofthebaselineriskofstroke

4.1.2

PatientsUndergoingElectiveCardioversionofAF（<48h）serialimagingofthepatientswithAFofdocumenteddurationof48horlessundergoingelectiveelectricalorpharmacologiccardioversionanticoagulation

atpresentationandproceedingtocardioversion（2C)Anticoagulationatleast4weeksafter(2C)regardlessofthebaselineriskofstroke

4.2

PatientsUndergoingUrgentCardioversionforHemodynamicallyUnstableAFserialimagingoftheAFpatientsandhemodynamicinstability

undergoingurgentcardioversiontherapeutic-doseparenteralanticoagulationbefore（2C)ifpossibleAnticoagulationatleast4weeksafter(2C)regardlessofthebaselineriskofstroke治療劑量：Enoxaparin1mg/kgbidor1.5mg/kgdailyprophylactic-dose：enoxaparin30mgbidor40mgdailyAnintermediate-doseregimen：forbridgingandisintermediateinanticoagulantintensitybetweenhigh-andlow-doseregimens(eg,enoxaparin40mgbid)傳統(tǒng)凝血模式分為內(nèi)源性及外源性凝血途徑內(nèi)源性(接觸因子)途徑外源性(組織因子)途徑XIaXIIaIXaXaIIaVIIIaVaVIIa組織因子纖維蛋白原纖維蛋白激活激活激活激活激活激活DunnCJ,etal.Drugs.2000(60)1:203-237三大抗凝體系