特殊情况的抗栓治疗台州

特殊情况的抗栓治疗台州第1页/共36页缺血性脑卒中脑出血转化HI出血性梗死：HI1小点状出血HI2多个融合的点状出血PH脑实质出血PH1≤30%梗死灶有轻微占位效应出血PH2＞30%梗死灶有明显占位效应出血或远离梗死灶出血第2页/共36页缺血性脑卒中出血转化的抗栓治疗2010中国卒中急性期指南第3页/共36页缺血性脑卒中出血转化的抗栓治疗3.对于出血性脑梗死患者，根据患者的临床情况（无症状和出血量少）及抗凝适应症时，可以考虑继续抗凝。ClassIIb;LevelofEvidenceCGuidelinesforthePreventionofStrokeinPatientsWithStrokeandTransientIschemicStroke.publishedonlineMay1,2014第4页/共36页特殊情况的抗栓治疗缺血性脑卒中脑出血转化颅内出血房颤合并冠心病围手术期管理缺血性脑血管疾病患者抗栓治疗第5页/共36页脑出血后重新开始抗栓治疗的决策制定，依赖于随后的动脉或静脉血栓栓塞的风险大小、脑出血再发的风险、病人的全身情况，所以对每个病人必须制定个体化的方案。*脑梗死风险相对较低病人（如房颤但没有缺血性脑卒中史）和脑出血再发风险较高（如高龄的脑叶出血或可疑淀粉样脑血管病患者）或者整个神经系统功能很差，可以考虑应用抗血小板药物来预防缺血性脑卒中。颅内出血后的抗凝治疗ClassIIb;LevelofEvidenceBGuidelinesforthePreventionofStrokeinPatientsWithStrokeandTransientIschemicStroke.publishedonlineMay1,2014第6页/共36页2.对于急性脑出血、蛛网膜下腔出血或硬脑膜下出血后，何时恢复或开始抗凝治疗，最佳时机尚无定论。大多数病人来说，发病至少1周以上较为合理颅内出血后的抗凝治疗:ClassIIb;LevelofEvidenceBGuidelinesforthePreventionofStrokeinPatientsWithStrokeandTransientIschemicStroke.publishedonlineMay1,2014第7页/共36页特殊情况的抗栓治疗缺血性脑卒中脑出血转化颅内出血房颤合并冠心病围手术期管理缺血性脑血管疾病患者抗栓治疗第8页/共36页ForpatientswithAFandstablecoronaryarterydisease(eg,noacutecoronarysyndromewithinthepreviousyear)whochooseoralanticoagulationsuggestadjusted-doseVKAtherapyalone(targetINRrange,2.0-3.0)ratherthanthecombinationofadjusted-doseVKAtherapyandaspirin(Grade2C)AntithromboticTherapyforAtrialFibrillation

AntithromboticTherapyandPreventionofThrombosis,9thed：AmericanCollegeofChestPhysiciansEvidence-BasedClinicalPracticeGuidelines

第9页/共36页ForpatientswithAFat

intermediatetohighriskofstroke(eg,CHADS2score≥1)whoexperienceanacutecoronarysyndromeanddonotundergointracoronarystentplacementsuggestforthefirst12monthsadjusted-doseVKAtherapy(INR2.0-3.0)plussingleantiplatelettherapyratherthandualantiplatelettherapy(eg,aspirinandclopidogrel)ortripletherapy(eg,warfarin,aspirin,andclopidogrel)(Grade2C).AntithromboticTherapyforAtrialFibrillation

AntithromboticTherapyandPreventionofThrombosis,9thed：AmericanCollegeofChestPhysiciansEvidence-BasedClinicalPracticeGuidelines

第10页/共36页ForpatientswithAFatintermediatetohighriskofstrokeAfterthefirst12monthsantithrombotictherapyissuggestedasforpatientswithAFandstablecoronaryarterydiseaseAntithromboticTherapyforAtrialFibrillation

AntithromboticTherapyandPreventionofThrombosis,9thed：AmericanCollegeofChestPhysiciansEvidence-BasedClinical

PracticeGuidelines

第11页/共36页ForpatientswithAFathighriskofstroke(eg,CHADS2score≥2)duringthefirstmonthafterplacementofabare-metalstentorthefirst3to6monthsafterplacementofadrug-elutingstentsuggesttripletherapy(eg,VKAtherapy,aspirin,andlopid-ogrel)ratherthandualantiplatelettherapy(eg,aspirinandclopidogrel)(Grade2C)AntithromboticTherapyforAtrialFibrillation

AntithromboticTherapyandPreventionofThrombosis,9thed：AmericanCollegeofChestPhysiciansEvidence-BasedClinicalPracticeGuidelines

第12页/共36页ForpatientswithAFathighriskofstrokeAfterthisinitialperiodoftripletherapysuggestaVKA(INR2.0-3.0)plusasingleantiplateletdrug

ratherthanVKAalone(Grade2C).12monthsafterintracoronarystentplacementantithrombotictherapyissuggestedasforpatientswithAFandstablecoronaryarterydiseaseAntithromboticTherapyfor

AtrialFibrillation

AntithromboticTherapyandPreventionofThrombosis,9thed：AmericanCollegeofChestPhysiciansEvidence-BasedClinicalPracticeGuidelines

第13页/共36页patientswithnonvalvularAFCHA2DS2-VAScscoreisrecommendedforassessmentofstrokerisk

(LevelofEvidence:B)highriskofstrokewithpriorstroke,transientischemicattack(TIA)oraCHA2DS2-VAScscoreof2orgreater《2014AHA/ACC/HRSGuidelinefortheManagementofPatientsWithAtrialFibrillation》第14页/共36页ForpatientswithnonvalvularAForalanticoagulantsarerecommendedOptionsinclude:warfarin(INR2.0to3.0)(LevelofEvidence:A)dabigatran

(LevelofEvidence:B),rivaroxaban(LevelofEvidence:B)apixaban(LevelofEvidence:B)《2014AHA/ACC/HRSGuidelinefortheManagementofPatientsWithAtrialFibrillation》第15页/共36页patientswithAFundergoingpercutaneouscoronaryinterventionbare-metalstentsmaybeconsideredtominimizetherequireddurationofdualantiplatelettherapyFollowingcoronaryrevascularization(percutaneousorsurgical)inpatientswithAFandaCHA2DS2-VAScscoreof2orgreater,itmaybereasonabletouseclopidogrel(75mgoncedaily)concurrentlywithoralanticoagulantsbutwithoutaspirin

(LevelofEvidence:B)《2014AHA/ACC/HRSGuidelinefortheManagementofPatientsWithAtrialFibrillation》第16页/共36页WOEST试验比较了华法林、氯吡格雷加或不加阿司匹林的双联与三联治疗结果显示华法林加氯吡格雷的双联治疗出血风险更低（p＜0.001），1年次要临床终点（包括死亡、心肌梗死、卒中）发生率降低（p=0.025）血栓栓塞风险并不增加指南对这种抗栓方案更为推崇《2014AHA/ACC/HRSGuidelinefortheManagementofPatientsWithAtrialFibrillation》第17页/共36页特殊情况的抗栓治疗缺血性脑卒中脑出血转化颅内出血房颤合并冠心病围手术期管理缺血性脑血管疾病患者抗栓治疗第18页/共36页缺血性脑血管疾病患者抗栓治疗

围手术期管理围手术期的抗血栓形成治疗必须评估继续用药所致的出血风险停药所致的血栓栓塞风险Summaryofevidence-basedguideline:Periproceduralmanagementofantithromboticmedicationsinpatientswithischemiccerebrovasculardisease,Neurology80May28,2013第19页/共36页缺血性脑血管疾病患者抗栓治疗

围手术期管理暂停抗栓药物的血栓栓塞风险？继续使用抗栓药物的围手术期出血风险？如暂停口服抗凝药，需要过渡性治疗吗？如果停用抗栓药物，该停多长时间？Summaryofevidence-basedguideline:Periproceduralmanagementofantithromboticmedicationsinpatientswithischemiccerebrovasculardisease,Neurology80May28,2013第20页/共36页暂停抗血小板药物

所致血栓栓塞的风险oneClassIstudy1and2ClassIIstudies暂停阿司匹林很可能增加脑卒中或短暂性脑缺血发作风险发生脑卒中风险与阿司匹林停止时间长短相关停药2周的相对危险度（RR）为1.97停药4周的比值比（OR）为3.4停药5月的相对危险度（RR）为1.40Summaryofevidence-basedguideline:Periproceduralmanagementofantithromboticmedicationsinpatientswithischemiccerebrovasculardisease,Neurology80May28,2013第21页/共36页暂停抗凝药物所致血栓栓塞风险不同抗凝适应症，停用抗凝药所致血栓栓塞风险各异。继续使用华法林和停用华法林（有或没有围手术期肝素过渡性治疗）条件下血栓栓塞的风险，尚缺乏大样本的研究。停用华法林超过7天，导致血栓栓塞的风险高达(RR5.5)(oneClassIstudy)

Summaryofevidence-basedguideline:Periproceduralmanagementofantithromboticmedicationsinpatientswithischemiccerebrovascular

disease,Neurology80May28,2013第22页/共36页第23页/共36页中华医学会心血管病学分会,《中华心血管病杂志》编辑委员会.中华心血管病杂志,2013.183-194.第24页/共36页如暂停口服抗凝药，需要过渡性治疗吗？没有足够证据肝素过渡性治疗减少血栓栓塞事件大多数研究提示肝素过渡性治疗可能增加围手术期出血风险。2个一级证据、1个二级证据、1个三级证据的临床研究，肝素过渡性治疗可增加出血风险另1个一级证据的临床研究，没有实质性地增加风险。也没有足够证据发现“继续服用口服抗凝药与肝素过渡性治疗间血栓栓塞风险差别”另有1个一级证据临床研究发现，牙科手术，使用低分子肝素过渡性治疗与继续服用抗凝药相比，出血风险很可能相似。Summaryofevidence-basedguideline:Periproceduralmanagementofantithromboticmedicationsinpatientswithischemiccerebrovasculardisease,Neurology80May28,2013第25页/共36页如果停用抗栓药物，该停多长时间？尚无足够的证据支持任何明确的结论抗栓作用时间阿司匹林和氯吡格雷预计可达7天单次量的华法林作用时间预计为2-5天逆转抗栓作用时间，一般推荐抗血小板药物停止7-10天华法林停止5天也有很多回顾性分析，提示停药时间可更短。Summaryofevidence-basedguideline:Periproceduralmanagementofantithromboticmedicationsinpatientswithischemiccerebrovasculardisease,Neurology80May28,2013第26页/共36页推荐牙科操作，继续使用阿司匹林，很可能（highlyunlikely）不增加临床意义的出血性并发症。缺血性脑卒中患者接受牙科手术时应常规地继续服用阿司匹林(LevelA)。Summaryofevidence-based

guideline:Periproceduralmanagementofantithromboticmedicationsinpatientswithischemiccerebrovasculardisease,Neurology80May28,2013第27页/共36页推荐继续使用阿司匹林可能（probably）不增加临床意义的出血性并发症眼部麻醉、白内障手术、皮肤科小手术和操作、经直肠超声引导下前列腺穿刺、腰穿/硬膜外操作、腕管手术(LevelB)鉴于很小临床意义出血风险脑卒中患者接受上述操作时也许应该继续使用阿司匹林(LevelB)。Summaryofevidence-basedguideline:Periproceduralmanagementofantithromboticmedicationsinpatientswithischemiccerebrovasculardisease,Neurology80May28,2013第28页/共36页推荐继续使用阿司匹林可能（might）不增加临床意义出血并发症玻璃体视网膜手术、肌电图、经支气管镜肺活检、肠镜检查、息肉切除术、胃镜检查和活检、括约肌切开术、腹部超声引导下活检较弱证据支持较小临床意义出血风险高危血栓栓塞风险脑卒中病人接受上述操作时可能应该继续使用阿司匹林(LevelC)。Summary

ofevidence-basedguideline:Periproceduralmanagementofantithromboticmedicationsinpatientswithischemiccerebrovasculardisease,Neurology80May28,2013第29页/共36页推荐虽然出血性不良事件罕见经尿道前列腺切除术，继续使用阿司匹林增加临床意义出血风险没有达统计学差异(LevelU).Summaryof

evidence-basedguideline:Periproceduralmanagementofantithromboticmedicationsinpatientswithischemiccerebrovasculardisease,Neurology80May28,2013第30页/共36页推荐髋部骨科手术继续服用阿司匹林很可能（probably）增加出血风险(LevelB).

Summaryof

evidence-basedguideline:Periproceduralmanagementofantithromboticmedicationsinpatientswithischemiccerebrovasculardisease,Neurology80May28,2013第31页/共36页推荐牙科操作，继续使用华法林很可能（highlyunlikely）不增加临床意义的出血性并发症(LevelA).鉴于出血风险小缺血性脑卒中病人接受牙科操作时应常规继续使用华法林(LevelA).Summaryofevidence-basedguideline:Periproceduralmanagementofantith