STEMI STEMIPCI 2017 STEMI 1 Routine postprocedural anticoagulant

STEMI患者抗凝� 状 抗凝是STEMI直接PCI治疗的基石 术后抗凝治疗证据不足 2017 欧洲心脏病学会 STEMI 指南 1 Routine post-procedural anticoagulant therapy is not indicated after primary PCI, except when there is a separate indication for either full-dose anticoagulation [due, for instance, to atrial fibrillation (AF), mechanical valves, or LV thrombus) or prophylactic doses for the prevention of venous thromboembolism in patients requiring prolonged bed rest. 仅建议高危患者术后应用抗凝，不建议常规应用 2013 美国心脏病学会 STEMI 指南 2 Patients with STEMI undergoing reperfusion with fibrinolytic therapy should receive anticoagulant therapy for a minimum of 48 hours, and preferably for the duration of the index hospitalization, up to 8 days or until revascularization if performed. (Level of Evidence: A) Recommended regimens include: UFH, Enoxaparin and Fondaparinux 仅建议溶栓后患者，未提及急诊PCI患者 1. Eur Heart J. 2018 Jan 7; 39(2): 119 -177 2. J Am Coll Cardiol. 2013 Jan 29; 61(4): e 78 -140 4

真实世界中的术后抗凝 导管室PCI术前/术中或术后应用抗凝药物情况 比伐芦定 14, 10% 4, 90% 0, 90% 低分子肝素 3, 40% 62, 50% 肝素 2, 20% 0% 10% 20% 30% PCI�前/�中 40% 50% PCI�后 Leonardo De Luca, et al. EYESHOT, J Cardiovasc Med 2017, 18: 580– 589. 60% 70%

STEMI患者血栓负荷更重 STEMI (n = 29) NSTEACS (n = 22) p 纤维化面积, mm 2 7. 28 ± 2. 45 5. 72 ± 2. 22 0. 03 脂质面积, mm 2 1. 47 ± 0. 61 1. 06 ± 0. 58 0. 02 坏死区域, mm 2 6. 83 ± 3. 80 4. 79 ± 3. 91 0. 04 钙化区域, mm 2 0. 34 ± 0. 33 0. 29 ± 0. 25 0. 8 最小管腔面积特点 MLA, 最小管腔面积 Takaoka N, et al. Int J Cardiol. 2014 Feb 15; 171(3): 423 -30.

NSTE-ACS: LMWH延长应用的获益 死亡/心肌梗死 (慢性期发生的事件) RR FRISC I - 40 days 1. 04 FRISC II - 30 days 0. 52 FRIC 0. 92 - 45 days TIMI 11 B - 43 days 0. 91 Total 0. 83 (0. 67 -1. 02) 0. 7 1 1. 3 1. 6

有RCT证据的抗凝药物 可应用于STEMI患者术后的抗凝药物 肝素 Ex. TRACT-TIMI 251 STEMI溶栓患者 初始12 U/kg 持续 48小时 依诺肝素 Ex. TRACT-TIMI 251 STEMI溶栓患者 1 mg/kg Q 12 h 持续 7天 ATLAST 3 支架血栓高危患者 40 mg Qd 持续 14天 ATOLL 2 直接PCI患者 根据ACT调整用药 持续 4. 1天 ATOLL 2 直接PCI患者 住CCU期间 40 mg Qd 持续 4. 6天 1. Antman EM, et al. N Engl J Med. 2006 Apr 6; 354(14): 1477 -88. 2. G Montalescot, et al. Lancet. 2011 Aug 20; 378(9792): 693 -703. 3. Wayne B, et al. J Am Coll Cardiol. 2001 Nov 15; 38(6): 1608 -13. 比伐芦定 EUROMAX 4 STEMI直接PCI患者 1. 75 mg/kg(22. 5%) 0. 25 mg/kg(77. 5%) 持� 4. 5小� BRIGHT 5 直接PCI患者 1. 75 mg/kg(100%) 持� 3小� MATRIX 6 第三次随机：术 后比伐芦定组 vs 非抗凝组 ACS直接PCI患者 1. 75 mg/kg(34. 4%) 0. 25 mg/kg(59. 0%) 持� 6. 2小� 4. Steg PG, et al. N Engl J Med. 2013 Dec 5; 369(23): 2207 -17. 5. Han Y, et al. JAMA. 2015 Apr 7; 313(13): 1336 -46. 6. M. Valgimigli, et al. N Engl J Med. 2015; 373: 997 -1009.