老年房颤患者的抗栓治疗

<正>近10余年来,大量循证医学证据显示,抗栓治疗可使心房颤动(房颤)患者明显获益。2010年ESC房颤治疗指南中,已将房颤的抗栓治疗摆在了房颤三大治疗之首,这足以显示抗栓治疗的重要性[1]。但是,老年房颤患者抗栓治疗获益的同时,有较高的出血风险。此外,老年人往往罹患多种疾病而服多种药物,药物之间的相互作用,可能影响抗栓药物的代谢和疗效。老年患者的各种高危因素,使抗栓治疗复     

心房颤动抗凝治疗现状及新进展

<正> 心房颤动(房颤)是临床上最常见的持续性心律失常,患病率为1%,其发病人数随着年龄递增。在年龄>70岁的人群中已达7%～8%,年龄>80岁可达10%。2003年我国首次房颤大规模流行病学研究表明,中国房颤患病率为0.77%,且随年龄增长而显著增加,年龄>80岁人群可达7.5%。房颤可引起血栓性脑卒中等严重的并发症。Wolf等研究表明,在美国所有脑卒中患者中,有15%是由于房颤所引起。中华医学会组织的国内40家医院房颤回顾性研究表明,非瓣膜性房颤脑卒中的平均患病率为24.15%,年龄>80岁高达32.86%。     

206例老年心房颤动患者抗栓治疗及血管事件发生情况5年随访

目的分析老年心房颤动(房颤)患者近5年抗栓治疗现状及血管事件发生情况。方法回顾性分析2005年1月～2006年6月入住我院的年龄≥75岁房颤患者206例,记录主要合并疾病、抗栓治疗方法及5年内栓塞、严重出血及死亡事件发生情况。结果 206例房颤患者中共发生栓塞事件47次,年发生率为4.56%。严重出血事件3次,年发生率为0.29%。行阿司匹林抗血小板治疗70例,氯吡格雷治疗66例,氯吡格雷联合阿司匹林抗血小板治疗11例,未行抗栓治疗56例。行华法林抗凝治疗3例,随访期间更换为抗凝治疗11例。抗凝时间平均2年1个月。结论老年房颤患者栓塞事件年发生率高,预防栓塞具有重要的临床意义。华法林抗凝治疗率低,抗凝治疗时间短。     

心房颤动合并冠状动脉支架置入术患者的联合抗栓优化策略

心房颤动患者合并冠状动脉支架置入术后应接受口服抗凝药和双联抗血小板药的三联抗栓治疗。然而,华法林联合阿司匹林和氯吡格雷的三联抗栓治疗出血风险高,哪种联合方式更加安全有效便成为抗栓治疗优化策略的关注焦点。现就心房颤动合并冠状动脉支架置入术患者的各种联合抗栓治疗方案的有效性及安全性综述如下。     

冠心病抗栓治疗

<正> 由于血栓在动脉粥样硬化进展及并发症发生中的重要地位,抗栓治疗已经成为冠心病治疗的基石。抗栓治疗包括抗血小板治疗和抗凝治疗。针对冠心病不同临床类型,抗栓治疗的策略也不尽相同。1抗血小板药物抗血小板治疗贯穿了冠心病急性期和长期治疗的始终,目前具有循证医学证据的抗血小板聚集的药物有3类。1.1 阿司匹林阿司匹林主要作用机制是使血小板内环氧化酶失活,抑制血栓素A_2生成,从而抑制血小板的聚集。     

冠心病合并心房颤动患者冠状动脉介入治疗术后抗栓治疗调查及随访

目的:调查冠心病合并永久性非瓣膜病心房颤动(房颤)患者在冠状动脉介入治疗(PCI)术后的抗栓治疗情况并随访。方法:选取2000年1月～2005年9月我院因冠心病行PCI术入院并伴有永久性非瓣膜病房颤的患者62例,将资料完整的56例患者分为华法林治疗组(n=33)和非华法林治疗组(n=23),了解患者术后抗凝和抗血小板治疗状况,并对患者在PCI术后1年进行电话或门诊随访。结果:56例患者年龄(69.6±8.9)岁。PCI术后有33例(58.9%)房颤患者抗栓治疗中含华法林;23例(41.1%)术后未使用华法林。女性患者中应用华法林治疗的比例较男性低(P<0.05)。随访期间非华法林治疗组2例发生脑栓塞,与华法林治疗组比较栓塞发生率(8.7%比0)有增高趋势,但差异未达到统计学意义(P=0.08)。支架内再狭窄率和严重出血发生率非华法林治疗组与华法林治疗组比较均无统计学差异(P>0.05)。结论:由于缺乏大规模临床试验证据,对于既有抗凝又有联合抗血小板治疗指征的永久性房颤患者在PCI术后,实际临床上给予患者的抗栓治疗方法有多种,对于这部分患者的抗栓治疗需要更大规模的研究以指导临床治疗。     

心房颤动合并冠心病患者抗栓治疗分析

目的 探讨非瓣膜病心房颤动合并冠心病患者抗栓治疗方案及华法林治疗后大出血发生情况.方法 回顾性分析2005年1月至2009年12月北京同仁医院住院的非瓣膜病心房颤动合并冠心病患者134例,记录基线特征、抗凝和抗血小板治疗方案,门诊或电话随访血栓栓塞、出血及主要心脏事件发生情况.结果 134例患者年龄(73.8±7.8)...     

双通道抗栓:老年慢性冠心病高危患者抗栓治疗的新思路

目前,心血管疾病仍然是全球最主要的死因,2017年已造成全球约1780万人死亡[1].该病最常见的死因是缺血性心脏病.冠状动脉粥样硬化性心脏病(冠心病)是缺血性心脏病的主要类型.因其病程动态特性带来各异的临床表现,可被归类为急性冠状动脉综合征(acute coronary syndrome,ACS)或慢性冠状动脉综合征...     

冠心病患者支架置入术后监测血小板聚集率的临床意义

目的观察冠心病患者支架置入术后应用阿司匹林和氯吡格雷联合抗血小板治疗后,监测血小板聚集率并探讨其临床意义。方法测定562例冠心病患者,术前,术后3、7天,1、3、6个月二磷酸腺苷(ADP)和花生四烯酸(AA)诱导的血小板聚集率。ADP和AA分别按照血小板抑制率<40%和≥40%进行分组。ADP诱导血小板抑制率<40%组(75例)和≥40%组(487例)。AA诱导血小板抑制率<40%组(67例)和≥40%组(495例)。观察支架术后冠心病患者6个月的主要心脑血管事件。结果ADP和AA诱导的血小板抑制率<40%和≥40%两组分别比较一般临床资料,差异无显著性意义。随访6个月主要心脏事件的发生率:ADP诱导血小板抑制率<40%组高于≥40%组(30.7%vs12.9%,P<0.05);AA诱导血小板抑制率<40%组也高于≥40%组(28.1%vs11.7%,P<0.05)。出血不良事件没有显著差异。结论冠心病患者支架置入术后的血小板抑制率与6个月的主要心脑血管事件相关。     

心房颤动的抗栓与抗血小板治疗

目的:了解临床实践中心房颤动(房颤)患者抗栓治疗的现状及分析。方法:调查2003年(225例) -2004年(280例)年间有血栓栓塞高危因素的房颤患者接受抗栓治疗的情况。结果:发现2年间高危因素有明显增加(由平均1．4个增加到1．8个),但接受抗栓治疗均以阿司匹林为主(64．8％与72．5％),服用华法林的比例很低(4．0％与6．25％),且剂量均偏低。结论:临床实践中房颤接受抗栓治疗达到标准的比例很低,接受阿司匹林治疗者较多,但剂量偏少,接受华法林治疗者很少,房颤的抗栓治疗尚需进一步规范。     

Antithrombotic treatment in anticoagulated atrial fibrillation patients undergoing percutaneous coronary intervention

Coronary artery disease coexists in a clinically relevant number of patients with atrial fibrillation and it often requires percutaneous coronary intervention. These patients represent a particular challenge for clinicians in terms of antithrombotic management. They require combined antiplatelet–anticoagulant therapy to reduce the risk of recurrent ischemic cardiac events and stroke; however, this antithrombotic strategy is associated with an increased risk of bleeding complications. In the absence of randomized, controlled clinical trials, the majority of current recommendations rely on the results of cohort studies, meta-analyses, post-hoc analyses and subgroup analyses of large, phase III studies. Based on the available evidence, the present review discusses the optimal antithrombotic strategy for patients receiving chronic anticoagulant therapy due to atrial fibrillation who require antiplatelet treatment after acute coronary syndrome and/or percutaneous coronary intervention, and discusses the issue of dental procedures. The correct planning of therapy significantly reduces the risk of bleeding complications and thromboembolic events.Key messagesIn order to reduce the occurrence of recurrent cardiac ischemic events and stroke, anticoagulated patients with acute coronary syndrome and/or percutaneous coronary intervention require a combination of therapies including anticoagulants and antiplatelet drugs.Using the newest optimal combination of therapeutic strategies reduces the risk of haemorrhagic complications.     

心房颤动的抗栓治疗

心房颤动（房颤）是缺血性脑卒中的一个重要的独立危险因素。房颤可使各年龄段患者脑卒中的危险增加4～5倍,其年发生率随年龄而增加,50～59岁为1.5%,60～69岁为2.8%,70～79岁为9.9%,80～89岁为23.5%,平均为4.5%。由非瓣膜性房颤引起缺血性脑卒中的年发生率为5％。是无房颤者的2～7倍。若考虑短暂性脑缺血发作（TIA）和无症状的脑卒中,则年发生率为7％。因此,对于房颤患者,预防缺血性脑卒中的发生对于减少致残率和死亡率尤为重要。     

冠状动脉内支架植入术后的抗血小板治疗

冠状动脉内支架植入术是治疗冠心病的重要手段之一 ,亚急性血栓形成是支架术后早期冠状动脉闭塞的主要原因 ,术后抗血小板药物的应用尤为重要。临床常用的抗血小板药物有三种 :噻氯吡啶 ,氯吡格雷及西洛他唑。多项临床试验对以上三种药物进行了研究 ,比较了它们的优缺点。目前以氯吡格雷加阿司匹林联合使用最为广泛 ,对预防冠状动脉内亚急性血栓形成的效果满意 ,消化道及血液系统副作用较少     

Aspirin desensitization in patients undergoing percutaneous coronary interventions with stent implantation

The aim of this study was to test the safety and efficacy of a novel rapid desensitization procedure in patients with acetylsalicylic acid sensitivity and coronary artery disease who underwent cardiac catheterization and coronary stent implantation. Aspirin plays a key role in the secondary prevention of atherothrombotic events and thrombotic complications after stent implantation. Aspirin sensitivity not only limits patients to benefit from the long-term use of this antiplatelet agent but is also often an impediment to the implantation of bare-metal and drug-eluting coronary stents. Of 1,014 patients admitted for cardiac catheterization, 26 (2.6%) had histories of aspirin sensitivity characterized by respiratory or cutaneous manifestations (none had previous anaphylactic reactions); of these, 61.5% presented with acute coronary syndromes. All patients underwent a novel rapid desensitization challenge procedure before cardiac catheterization, except for those presenting with ST-elevation myocardial infarctions (n = 4), who underwent desensitization before hospital discharge. The desensitization procedure involved the oral administration of 6 sequential doses of aspirin (1, 5, 10, 20, 40, and 100 mg) over 5.5 hours without the use of corticosteroids or antihistamines. Patients were followed for 1 year to assess compliance with aspirin therapy and adverse events. The desensitization procedure was successful in 23 patients (88.5%). Percutaneous coronary intervention with stent implantation was performed in 22 patients (1.8 stents/patient). Drug-eluting stents were used in all patients except those who underwent primary percutaneous coronary intervention (n = 3), in whom bare-metal stents were used. Multivessel percutaneous coronary intervention was performed in 30.7% of patients. At follow-up, all patients who successfully responded to the desensitization procedure tolerated aspirin well, without developing allergic reactions. Aspirin was withdrawn in only 1 patient, because of a peptic ulcer. In conclusion, rapid desensitization is safe and highly effective in patients with aspirin sensitivity and coronary artery disease who undergo coronary stent implantation, including those who receive drug-eluting stents.     

老年非瓣膜病心房颤动患者的抗凝治疗

心房颤动已经成为严重威胁老年人健康的慢性疾病，而老年房颤最常见的并发症即为脑卒中及其他血管栓塞事件，其致残率及致死率高。但临床中老年房颤患者抗凝不足，故老年房颤患者抗凝治疗甚为重要。     

Antithrombotic therapy in atrial fibrillation

Atrial fibrillation is a common condition affecting elderly individuals; as many as 10% of people older than age 80 years have AF. AF is also a potent risk factor for ischemic stroke, raising the risk of stroke fivefold. A set of consistent randomized controlled trials has demonstrated that long-term anticoagulation can largely reverse the risk of stroke attributable to AF. In these trials, anticoagulation generally proved quite safe, raising the risk of intracranial hemorrhage by less than 0.5% per year. The anticoagulation target for AF is INR 2 to 3 with INR 2.5 as the specific goal. The trials were much less consistent about the efficacy of aspirin, although it seems that aspirin has a small stroke-preventive effect. The recommended dose of aspirin is 325 mg per day. Because it raises the risk of hemorrhage and adds the burden of frequent monitoring of INR values, anticoagulation is recommended for those patients with AF at higher risk of stroke. Such higher risk is conferred by the following risk factors: (1) a history of a prior stroke, TIA, or other systemic embolic event; (2) a history of hypertension; (3) diabetes mellitus; (4) left ventricular dysfunction; (5) mitral stenosis; and (6) older age. The exact age threshold conferring sufficiently increased risk is uncertain, with some research indicating the threshold should be age 65 years, and other research indicating the threshold should be age 75 years. For lower-risk patients, aspirin is recommended. Future research should focus on the oldest patients with AF. These individuals face the highest risk of ischemic stroke without anticoagulation and the highest risk of major hemorrhage with anticoagulation. Only small numbers of such elderly patients were included in the randomized trials. Future research should also focus on improved risk stratification, allowing better targeting of anticoagulation. Discoveries of new antithrombotic agents and new drugs and devices for preservation of sinus rhythm could radically improve stroke-preventive strategies for AF.