1、主要内容主要内容 Characteristics of GP IIb/IIIa Inhibitors GP IIb/IIIa Inhibitors in ACS GP IIb/IIIa Inhibitors in STEMI GPIIb/IIIa Inhibitors and PCIGP IIb/IIIa Inhibitors in ACS16.7%15.6%14.5%11.6%Impact of Early PCI on 30 Day Death/MI10.2%10.1%7.8%5.9%PRISM PlusPURSUITDMNon-DM5%10%6.2%PlaceboGPIIb/IIIa I
2、nhibitor4.6%3.0%3.0%GPIIb/IIIa Inhibitors in ACS30-Day mortality results of a Meta-analysis*Circulation 2001;104:2767-71*PRISM,PRISM-PLUS,PARAGON A&B,PURSUIT,GUSTO-IVn=6,458n=23,072PCINo PCI5%10%4.0%PlaceboGPIIb/IIIa Inhibitor1.2%6.7%5.5%GPIIb/IIIa Inhibitors in Diabetic Patients with ACS Circulatio
3、n 2001;104:2767-2771 30-Day Mortalityof a Meta-analysis*n=1,279n=5,179*PRISM,PRISM-PLUS,PARAGON A&B,PURSUIT,GUSTO-IVGUSTO-IV Study DesignNon ST-segment elevation ACSMedical rx only planned(no angio or PCI)(n=7800)2590 ASA+UFH+Abciximab24h2598ASA+UFH or LMUH+placebo2612 ASA+UFH+Abciximab48h2598 2590
4、2612 Lancet 2001;357:1915-24 P=0.664P=0.235P=0.190GUSTO-IV30-Day outcomesLancet 2001;357:1915-243.9%5.1%8.0%8.2%5.6%3.4%4.3%5.9%9.1%0%2%4%6%8%10%DeathMIplaceboAbciximab 24hAbciximab 48hDeath,MI2.0%1.0%0.0%2.0%5.0%2.0%3.0%7.0%1.0%0%2%4%6%8%10%transfusionplatelet countplatelet countplaceboAbciximab 24
5、hAbciximab 48h 100,000 per L0.03 g/L)20151050051015202530Days After RandomizationPlacebo Group(N=1010)Abciximab Group(N=1012)Troponin 0.03 g/LLog-Rank p=0.02Troponin 0.03 g/LLog-Rank p=0.98JAMA 2006;295:1531-38%早期应用有效降低住院死亡率早期应用有效降低住院死亡率NRMI注册研究注册研究NRMI-NSTEMI Risk ScoreN=60770NSTEMI患者患者住 院 死 亡 率%NR
6、MI=National Registry of Myocardial Infarction.Peterson E,et al.J Am Coll Cardiol.2003;42:45-5330天死天死亡亡/心梗心梗绝绝对下降对下降(%)1.7%2.3%用用 药药 距距 离离 发发 病病 的的 时时 间间(n=2522)(n=2041)(n=3803)(n=1105)0%0.00.51.01.52.02.53.0 24 hours 1.7%2.3%2.8%越早用药越早用药 绝对获益越大绝对获益越大 PURSUIT研究：研究：GPIIb/IIIa VS 安慰剂安慰剂JAMA.2000;284:15
7、49-1558B BA AB BB B三、三、GP IIb/IIIa Inhibitors in STEMI 124.610.5514.77.374.610.54.50102030RapportISAR 2AdmiralCadillacACENo AbciximabAbciximab%GP IIb/IIIa Inhibitors in STEMIRAPPORTAbciximab in primary PTCA for STEMI 0 05 510101515death/MI/uTVRdeath/MIuTVRplacebo,N=242placebo,N=242Abciximab,N=241Abc
8、iximab,N=2419.9%3.3%5.0%2.1%5.4%1.2%7-day Outcome0 05 510101515death/MI/uTVRdaeth/MIuTVRplacebo,N=242Abciximab,N=241 RAPPORT11.2%5.8%5.8%4.6%6.6%1.7%30 Day follow-up0 01010202030304040death/MI/TVRdeath/MI/uTVRdeath/MIplacebo,N=191placebo,N=191Abciximab,N=218Abciximab,N=21828.1%28.2%17.8%11.6%11.2%8.
9、7%RAPPORT6 month follow-upPrimary PTCA(n=518)MultiLink stent+Abciximab(n=524)Primary PTCA+Abciximab(n=528)MultiLink stent(n=512)CADILLACAMI 12 h,cardiogenic shock excluded N=208276 centers in N.A.S.A.and EuropeN Engl J Med 2002;346:957-966OUTCOMEPTCA(N=518)PTCA PLUS ABCIXIMAB(N=528)STENTING(N=512)ST
10、ENTING PLUSABCIMAB(N=524)P VALUEPERCENTAt 30 daysDeath2.51.12.22.70.31Reinfarction0.80.81.00.80.97Disabling stroke0.20.00.20.20.79Revascularization of ischemic target vessel5.63.43.21.60.004Composite end point8.34.85.74.40.02Other adverse enents Target-vessel revascularization for any reason6.03.63.
11、41.60.002 Subacute thrombosis1.90.81.00.00.01 Hemorrhagic complication Severe0.60.40.20.80.58 Moderate2.52.34.32.50.18 Intracrantial hemorrhage0.00.00.00.20.99 Throbocytopenia(100,000 cells/mm3)1.44.02.64.00.02 Blood-product transfusion 3.75.14.15.00.62At 6 months(cumulative)Death4.52.53.04.20.23Rei
12、nfarction1.82.71.62.20.64Disabling stroke0.20.20.40.40.88Revascularization of ischemic target vessel15.713.88.35.20.001Composite end point20.016.511.510.20.001Target-vessel revascularization for any reason16.914.88.95.70.001CADILLACKaplan-Meier Estimates of the Clinical Outcomes at 30 Days and 6 Mon
13、thsN Engl J Med 2002;346:957-9660.0%1.0%0.8%1.9%0%1%2%3%4%5%PTCAPTCA+AbciximabStentStent+AbciximabCADILLAC30 day acute thrombosisN Engl J Med 2002;346:957-966CADILLAC thrombocytopenia and bleeding evntsPTCAPTCA/AbcxStent Stent/AbcxpBleeding -sever0.6%0.2%0.4%0.8%0.58 -moderate2.5%2.3%4.3%2.5%0.18 -i
14、ntrcranial0%0%0%0.2%0.99thrombocytopenia1.4%4.0%2.6%4.0%0.02Blood-product intrafusion3.7%5.1%4.1%5.0%0.62 N Engl J Med 2002;346:957-966 ADMIRAL研究研究P0.05P=NSP=NSP0.05PRISM-PLUS Angiographic Substudy:Tirofiban Increased Perfusion StatusP=0.002 for trend by proportional odds modelZhao X-Q,et al.Circula
15、tion.1999;100:1609-1615.GPIIb/IIIa受体拮抗剂治疗建议中高危中高危NSTE-ACS患者患者(尤其尤其TnTTnT、STST或糖尿病或糖尿病)，可在，可在氯吡格雷氯吡格雷+ASAASA基础上，基础上，加用加用GPIIb/IIIa拮抗剂拮抗剂不建议不建议STEMI患者溶栓时联合应用患者溶栓时联合应用GPIIb/IIIa受体拮抗剂受体拮抗剂，尤其是年龄，尤其是年龄大于大于7575岁的患者岁的患者GPIIb/IIIa拮抗剂应在抗凝治疗基础上应用拮抗剂应在抗凝治疗基础上应用(UFH或或LMWH)出血危险较高患者慎用或禁忌；若应用出血危险较高患者慎用或禁忌；若应用GPIIb
16、/IIIa受体拮抗剂，应监测受体拮抗剂，应监测血红蛋白和血小板计数血红蛋白和血小板计数B BA AB BB B四、四、GPIIb/IIIa Inhibitors and PCI trialsCasesOdds ratio&95%CIplaceboGPIEPIC2,0999.6%6.6%IMPACT-II4,0108.5%7.0%EPILOG2,7929.1%4.0%CAPTURE1,2659.0%4.8%RESTORE2,1416.3%5.1%EPISTENT2,39910.2%5.2%ESPRIT2,06410.2%6.3%Placebo betterGPI betterGPIIb/IIIa
17、 Inhibitors and PCImeta-Analysis30-day MI/death4.1%14.0%11.1%22.4%1.2%4.9%4.3%13.7%2.6%10.3%8.4%25.3%0%10%20%30%40%50%deathdeath,MIMITVRstent+placebo(n=173)stent+abciximab(n=162)angioplasty+abciximab(n=154)EPISTENT1-year results in diabetesstent+placebo VS angiolpasy+abciximabLancet 1999;354:2019-24
18、EPISTENTLancet 1999;354:2019-241.9%10.3%8.7%13.7%1.0%5.4%4.4%15.6%2.0%7.5%6.0%18.7%0%10%20%30%40%50%deathdeath,MIMITVRstent+placebo(n=635)stnet+abciximab(n=632)angiolasty+abciximab(n=640)Lancet 1999;354:2019-24EPISTENT1-year results in non-diabetesstent+placebo VS angiolpasy+abciximabP-valueOdds-rat
19、ioTirofibanAbciximab0.0387.6%6.0%Death0.660.5%0.4%0.046.9%5.4%0.047.2%5.7%0.490.8%0.7%N Engl J Med 2001;344:1888-94TARGET Tirofiban vs Abciximab in PCI30-day resultsTARGET Tirofiban vs Abciximab in PCI 6-month follow-upAbciximabTirofibanP-valueMACE13.8%14.4%0.5death1.0%1.1%0.9MI6.6%8.0%0.07TVR8.0%7.
20、5%0.5N Engl J Med 2001;344:1888-94ISAR-REACT abciximab in elective PCI0.30.43.30.90.30.53.30.7012345DeathQ-MINQ-MIUrgent TVRJ Am Coll Cardiol 2004;44:2133-36 exclude recent MI,ACS,diabetesALL=NSabciximabplacebo1.12.50.92.40.71.900.9012345major bleeding minor bleedingtransfusionJ Am Coll Cardiol 2004
21、;44:2133-36abciximabplacebothrombocytopeniaISAR-REACT abciximab in elective PCIsafety outcomesASA,clopidogrel,randomization in cath labPlacebo+Heparin 60U/kg bolus(ACT 200-300 sec)Eptifibatide180+180 g/kg bolus(boluses 10 min apart)2.0 g/kg-min infusion18-24o+Heparin 60 U/mg bolus(ACT 200-300sec)48
22、hour,30day,6 month,1 year follow-upElective PCIVS.Lancet 2000;356:2037-44RR=0.62 6.4%10.2%ESPRIT 30-Day resultsLancet 2000;356:2037-44Death or MI(%)0%2%4%6%8%10%12%102030PlaceboEptifibatide1.8%1.3%2.8%0.2%0.3%0.3%1.7%1.0%0.1%0.2%0.6%0.1%0.0%0.4%0.6%0.0%0%1%2%3%intracranialhemorrhagenon-hemorrhagicst
23、oke总体发生率总体发生率ACT 292monirbleeding(TIMI)platelet count 20,000Eptifibatide(n=1040)placebo(n=1024)*p45TortOstialThrombEccIrregLL10PlaceboAbciximab%p=.047EPIC and EPILOG:30 day Events(D,MI,uTVR)Abciximab in PCI:Complex Lesions p=.001 p=.001 p=.001 p=.001 p=.078 p=.001 p=.001 p=.001JACC 1998;32:1619-2374
24、.112.55.601020Type A/B1Type B2/CPlaceboAbciximab%EPISTENT Abciximab for Complex Lesions30 day D,MI,uTVRp=0.17p0.001Lancet 1999;354:2019-24B BA AB BB B小小 结结 血小板在血小板在ACS发病中起重要作用发病中起重要作用 抗血小板治疗是抗血小板治疗是ACS的关键治疗之一的关键治疗之一 GPb/a拮抗剂尤其适宜于中高危拮抗剂尤其适宜于中高危行介入治疗的行介入治疗的ACS患者患者 三重抗血小板治疗在三重抗血小板治疗在ACS伴伴TNI升高升高者中尤为重要者中尤为重要谢 谢！51 结束语结束语
