1、post-PCI围手术期抗血小板策略围手术期抗血小板策略浙江大学医学院附属第二医院浙江大学医学院附属第二医院心内科心内科 项美香项美香ACC/AHA/SCAI Focused Update of the Guideline for Percutaneous Coronary Intervention2007 Writing Committee MembersSpencer B.King III,MD,MACC,FAHA,FSCAI,Co-ChairSidney C.Smith,MD,FACC,FAHA,Co-ChairJohn W.Hirshfeld,Jr,MD,FACC,FAHA,FSCAI
2、Alice K.Jacobs,MD,FACC,FAHA,FSCAIDouglass A.Morrison,MD,PhD,FACC,FSCAIDavid O.Williams,MD,FACC,FAHA,FSCAIAntiplatelet TherapyA loading dose of clopidogrel,generally 600 mg,should be administered before or when PCI is performed.Modified recommendationIn patients undergoing PCI within 12 to 24 hours o
3、f receiving fibrinolytic therapy,a clopidogrel oral loading dose of 300mg may be considered.Modified recommendationFor all post-PCI stented patients receiving a DES,clopidogrel 75 mg daily should be given for at least 12 months if not at high risk of bleeding.Modified recommendationFor patients rece
4、iving BMS,clopidogrel should be given for a minimum of 1 month and ideally up to 12 months(unless at increased risk of bleeding).Modified recommendationI I IIIaIIaIIa IIbIIbIIb IIIIIIIIII I IIIaIIaIIa IIbIIbIIb IIIIIIIIII I IIIaIIaIIa IIbIIbIIb IIIIIIIIIIIaIIaIIa IIbIIbIIb IIIIIIIIII I I IIaIIaIIa I
5、IbIIbIIb IIIIIIIIII I I IIaIIaIIa IIbIIbIIb IIIIIIIIII I I IIaIIaIIa IIbIIbIIb IIIIIIIIIIIaIIaIIa IIbIIbIIb IIIIIIIIII I IIIaIIaIIa IIbIIbIIb IIIIIIIIII I IIIaIIaIIa IIbIIbIIb IIIIIIIIII I IIIaIIaIIa IIbIIbIIb IIIIIIIIIIIaIIaIIa IIbIIbIIb IIIIIIIIII I IIIaIIaIIa IIbIIbIIb IIIIIIIIII I IIIaIIaIIa IIb
6、IIbIIb IIIIIIIIII I IIIaIIaIIa IIbIIbIIb IIIIIIIIIIIaIIaIIa IIbIIbIIb IIIIIIIIIAntiplatelet TherapyIf clopidogrel is given at the time of procedure,supplementation with GP IIb/IIIa receptor antagonists can be beneficial.ModifiedFor patients with an absolute contraindication to aspirin,it is reasonab
7、le to give a 300 mg to 600 mg loading dose of clopidogrel,administered at least 6 hours before PCI,and/or GP IIa/IIIa antagonists at the time of PCI.No ChangeIn patients with increased risk of bleeding,a lower dose of 75 mg to 162 mg of aspirin is reasonable during the initial period after stent imp
8、lantation.NewContinuation of clopidogrel therapy beyond 1 year may be considered in patients undergoing DES placement.NewI I I IIaIIaIIa IIbIIbIIb IIIIIIIIII I I IIaIIaIIa IIbIIbIIb IIIIIIIIII I I IIaIIaIIa IIbIIbIIb IIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIII I I IIaIIaIIaIIbIIbIIbIIIIIIIIII I I IIaIIaII
9、aIIbIIbIIbIIIIIIIIII I I IIaIIaIIaIIbIIbIIbIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIII I IIIaIIaIIa IIbIIbIIb IIIIIIIIII I IIIaIIaIIa IIbIIbIIb IIIIIIIIII I IIIaIIaIIa IIbIIbIIb IIIIIIIIIIIaIIaIIa IIbIIbIIb IIIIIIIIII I I IIaIIaIIaIIbIIbIIbIIIIIIIIII I I IIaIIaIIaIIbIIbIIbIIIIIIIIII I I IIaIIaIIaIIbIIbIIb
10、IIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIAntiplatelet Therapy Patients already taking daily long-term aspirin should take 75 mg to 325 mg before PCI.No changes Patients not already taking daily aspirin should be given 300 mg to 325 mg of aspirin at least 2 hours and preferably 24 hours before PCI.No chan
11、ge After PCI,in patients without allergy or increased risk of bleeding,aspirin 162 mg to 325 mg daily should be given for at least:1 month after BMS 3 months after sirolimus-eluting stent 6 months after paclitaxel-eluting stent Modified recommendationI I IIIaIIaIIa IIbIIbIIb IIIIIIIIII I IIIaIIaIIa
12、IIbIIbIIb IIIIIIIIII I IIIaIIaIIa IIbIIbIIb IIIIIIIIIIIaIIaIIa IIbIIbIIb IIIIIIIIII I I IIaIIaIIa IIbIIbIIbIIIIIIIIII I I IIaIIaIIa IIbIIbIIbIIIIIIIIII I I IIaIIaIIa IIbIIbIIbIIIIIIIIIIIaIIaIIa IIbIIbIIbIIIIIIIIII I I IIaIIaIIa IIbIIbIIb IIIIIIIIII I I IIaIIaIIa IIbIIbIIb IIIIIIIIII I I IIaIIaIIa II
13、bIIbIIb IIIIIIIIIIIaIIaIIa IIbIIbIIb IIIIIIIIIAspirinAll post-PCI stented patients without aspirin resistance,allergy,or increased risk of bleeding should be given aspirin 162 mg to 325 mg daily for at least:1 month after BMS 3 months after sirolimus-eluting stent6 months after paclitaxel-eluting st
14、ent Long-term aspirin use should be continued indefinitely at 75 mg to 162 mg daily.Modified recommendationIn patients at increased risk of bleeding,lower-dose 75 mg to 162 mg of aspirin is reasonable during the initial period after stent implantation.New recommendationI I I IIaIIaIIa IIbIIbIIb III
15、III IIII I I IIaIIaIIa IIbIIbIIb III III IIII I I IIaIIaIIa IIbIIbIIb III III IIIIIaIIaIIa IIbIIbIIb III III IIII I I IIaIIaIIaIIbIIbIIbIIIIIIIIII I I IIaIIaIIaIIbIIbIIbIIIIIIIIII I I IIaIIaIIaIIbIIbIIbIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIAspirinn2006 Consensus of China:ASA100300mg q.d.after PCI at l
16、east 1 month.And then 75100mg q.d.AspirinnNo trials compared lower dose(75-162mg)with higher dose aspirin(162-325mg)as the initial course of therapy after DES in subacute or late stent thrombosisnThe recommendation according to the clinical trial protocolnHigher dose aspirin increase the risk of ble
17、edingnIn the patients at high risk of bleeding,the use of low dose of aspirin.AspirinnMajor bleeding events were more frequently in patients of taking SA 200mg+clopidogrel 75mg than that of taking ASA 100mg+clopidogrel 75mgnAntiplatelet effects could not be increased in higher dose of ASA Clopidogre
18、lFor all post-PCI patients who receive a DES,clopidogrel 75 mg daily should be given for at least 12 months if not at high risk of bleeding.For post-PCI patients receiving as BMS,it should be given for a minimum of 1 month and ideally up to 12 months(unless patient is at increased risk of bleeding t
19、hen it should be given for a minimum of 2 weeks).Modified recommendationFor all post-PCI non-stented STEMI patients,treatment with clopidogrel should continue for 14 days.New recommendationLong-term maintenance therapy(e.g.1 year)with clopidogrel is reasonable in STEMI and NSTEMI who undergo PCI wit
20、hout reperfusion therapy.New recommendationI I I IIaIIaIIa IIbIIbIIb III III IIII I I IIaIIaIIa IIbIIbIIb III III IIII I I IIaIIaIIa IIbIIbIIb III III IIIIIaIIaIIa IIbIIbIIb III III IIII I I IIaIIaIIaIIbIIbIIbIIIIIIIIII I I IIaIIaIIaIIbIIbIIbIIIIIIIIII I I IIaIIaIIaIIbIIbIIbIIIIIIIIIIIaIIaIIaIIbIIbI
21、IbIIIIIIIIII I I IIaIIaIIa IIbIIbIIb III III IIII I I IIaIIaIIa IIbIIbIIb III III IIII I I IIaIIaIIa IIbIIbIIb III III IIIIIaIIaIIa IIbIIbIIb III III IIIPerioperative periodnUnder urgent situation,the duration studied for FDA approval n3 months for SESn6 months for PESPredictors of late stent thromb
22、osisnSmall vesselsnMultiple lesionsnLong stentsnOverlapping stentsnOstial or bifurcation lesionsnSuboptimal stent resultnLow EFnAdvanced agenDMnRenal failurenASCPerioperative periodnElective surgery:postponed for 1 yearnNot be deferred surgery,aspirin therapy considered in high risk patients with DESnSurgery with low risk of bleeding,continue DAT
