替普瑞酮联合法莫替丁防治抗血小板药物所致胃肠道损伤的效果观察

目的观察替普瑞酮联合法莫替丁防治抗血小板药物所致胃肠损伤的疗效。方法选取2016年8月至2018年11月化州市人民医院收治的胃肠道损伤患者84例。依据治疗方法分为3组:质子泵抑制剂(PPI)组、H2受体拮抗剂(H2RA)组和联合治疗组,每组28例。所有患者均继续进行抗血小板治疗。PPI组服用泮托拉唑;H2RA组服用法莫替丁;联合治疗组在H2RA组基础上加服替普瑞酮。共治疗6个月。对比3组患者治疗前后各指标变化情况。采用SPSS 24.0软件进行数据处理。结果治疗后,联合治疗组患者的前列腺素E2(PGE2)显著高于PPI组和H2RA组[(83.46±16.83)vs(46.61±14.53)vs(55.67±18.49)ng/L],血栓素B2(TXB2)显著低于PPI组和H2RA组[(139.96±48.69)vs(297.38±44.09)vs(173.82±51.25)pg/L],基础胃酸分泌量高于PPI组、低于H2RA组[(3.86±0.67)vs(2.29±0.56)vs(4.97±0.89)mmol/h],差异具有统计学意义(P0.05)。治疗后联合治疗组患者胃[(0.76±0.37)vs(3.38±2.11)vs(3.04±1.93)分]和十二指肠[(0.81±0.32)vs(3.19±1.52)vs(2.91±1.49)分]黏膜的改良Lanza量表评分显著低于PPI组与H2RA组(P0.05)。联合治疗组患者不良反应发生率显著低于PPI组和H2RA组(17.9%vs 53.6%vs 28.6%,P0.05)。结论替普瑞酮联合法莫替丁防治抗血小板药物所致胃肠损伤的疗效显著且不良反应少,值得临床推广应用。     

抗血小板治疗与胃肠道出血新进展

冠心病是一种最常见的心脏病,斑块的不稳定、破裂以及血栓形成是贯穿于冠心病发病过程的主要矛盾,随着药物洗脱支架、经皮冠状动脉介入技术日趋成熟,置入药物洗脱支架后联合应用抗血小板聚集药物可明显减少心脏事件的发生。经抗血小板治疗在减少血栓事件的同时也给患者带来了出血的风险,一旦胃肠道出血则对抗血小板治疗形成了十分严峻的挑战,在临床中充分权衡二者的利弊,合理应用。     

抗血小板治疗

抗血小板药是一类能抑制血小板活化 ,进而阻止血小板参与血栓形成的药物 ,其在动脉血栓形成中的作用尤为突出 ,因而成为防栓、治栓的重要药物。1　传统抗血小板药物1.1　阿司匹林　基础研究表明 ,血小板在动脉粥样硬化斑块形成及动脉血栓形成中起关键作用。阿司匹林的作用机理是通过抑制环氧化酶 ,不可逆地阻断花生四烯酸至 TXA2 的途径 ,进而抑制血小板聚集。除了花生四烯酸途径之外 ,尚有 90余种途径可诱发血小板聚集 ,而阿司匹林仅为一种较弱的血小板抑制剂 ,大量临床试验均证实阿司匹林确能降低各种心血管疾病 (短暂心肌缺血、心肌梗…     

双重抗血小板治疗的胃肠道并发症

为预防和治疗心脑血管疾病及外周动脉血管病变,我们会联合应用阿司匹林和氯吡格雷行双重抗血小板治疗。在高危血管性疾病患者中行双重抗血小板治疗的获益可能会以胃肠道并发症为代价。严重的胃肠道并发症包括胃十二指肠溃疡所致胃肠道出血、穿孔和死亡。轻的并发症包括消化不良、药物性食管炎、上皮出血、糜烂以及胃十二指肠溃疡。进行抗血小板治疗出现胃肠道并发症的高危因素包括老年、有胃十二指肠溃疡病史、胃食管返流性疾病、食管炎、未治疗的Hp感染、肠道息肉或癌症以及抗凝剂、类固醇激素、非甾体类消炎药的使用。前列腺素合成被抑制…     

胶囊内镜在双联抗血小板药物导致胃肠道黏膜损害中的应用

双联抗血小板药物导致胃肠道黏膜损害是当前研究的热点。胶囊内镜是一种无痛的消化道检查方式,检查 范围已从小肠逐步扩展至食管、胃、结肠。目前,胶囊内镜已成为观察双联抗血小板药物和小剂量阿司匹林导致小肠 黏膜损伤的主要方式,其优势在于诊断准确性高、且患者依从性高,有利于长期随访和反复评估黏膜损伤情况。未 来,应用磁控胶囊胃镜观察胃部黏膜损伤将是下一个研究热点。     

冠心病高危患者抗血小板治疗研究进展

随着冠状动脉介入治疗的普及,有效的抗血小板治疗的重要性越来越受到重视.本文综述冠心病高危患者介入治疗后抗血小板治疗的应用现状、存在问题及处理策略,介绍近年来抗血小板药物的研发情况及应用前景.     

抗血小板药物

血小板在动脉血栓性疾病和动脉粥样硬化中起着重要作用。它通过释放前列腺素类物质和生长因子,形成血管内血栓等多种途径参与动脉粥样硬化的发展;神经体液因素、高血压、高血脂、糖尿病等造成血小板功能增强和(或)生存期缩短可促进或加重缺血性心脑血管病的进展和发作。     

冠心病抗血小板治疗的新进展

冠心病抗血小板治疗的新进展上海第二医科大学附属瑞金医院心内科陈晓文综述戚文航审校血小板的活化在心血管血栓性疾病的发生发展中起着重要的作用。近年来，随着阿斯匹林、噻氯匹定等抗血小板药物在冠心病防治中取得了显著疗效，不少新的该类药物进入了临床试用阶段。其...     

女性冠心病抗血小板治疗

心血管疾病已经超过了脑卒中和肿瘤,已成为威胁我国女性生命及健康的首要疾病。随着国内外多项循证医学结果的公布,人们逐渐认识到女性冠心病有许多不同于男性人群的流行病学特点,在危险因素、临床表现、治疗及预后等各方面与男性人群亦有一定程度的差异。作为冠心病的基础治疗,抗血小板治疗亦存在性别差异。现就近年来有关女性冠心病抗血小板治疗方面的相关进展做一简要概述。     

氯吡格雷对胃肠道的损害及其防治

氯吡格雷作为新型抗血小板药物, 其应用于心脑血管疾病的治疗已逾十年. 近来, 随着质子泵抑制剂(PPI)在预防氯吡格雷相关的胃肠道损害中心血管事件发生率和死亡率的升高, 氯吡格雷对胃肠道的损害及其防治引起了临床医师的广泛关注. 本文就氯吡格雷临床应用现状、对胃肠道的损害及其防治策略作一综述.     

抗血小板治疗对老年人胃肠道损伤的临床分析

目的 比较单用和联用抗血小板药物对老年人胃肠道损伤的风险,总结抗血小板治疗致胃肠黏膜损伤内镜特点.方法 对577例使用阿司匹林和(或)氯吡格雷的老年患者消化不良症状、消化道出血事件及内镜检查结果进行回顾性分析.结果 氯吡格雷组出现消化不良症状和消化道出血风险略高于阿司匹林组,但差异无统计学意义(x2=0.48、0.72,均P＞0.05),OR值(95%CI)分别为1.10(0.59～2.07)、1.74(0.48～6.33);阿司匹林+氯吡格雷组(联用组)有消化不良症状者较单用阿司匹林或氯吡格雷组无显著增加(x2=0.37、0.03,均P＞0.05),但消化道出血显著高于阿司匹林组(x2=5.43,P＜0.05),OR值(95%CI)4.77(1.15～19.79),略高于氯吡格雷组(P＞0.05).本组胃镜检查57例,糜烂或溃疡总检出率为45例(78.9%);糜烂多发生于胃窦部(61.4%),溃疡多发生于胃窦、胃角(10.6%)及十二指肠球部溃疡(18.0%);有消化不良症状者内镜下以糜烂为主(70.5%),消化道出血者则以溃疡为主(69.2%).结论 老年患者单用氯吡格雷发生消化不良症状及出血者,比单用小剂量阿司匹林者未见减少,阿司匹林+氯吡格雷联合使用可增加胃肠道出血的风险.抗血小板治疗有症状者内镜下糜烂或溃疡的检出率高,有消化不良症状者以糜烂为主,消化道出血者以溃疡为主,且复合溃疡多见.

Abstract：

Objective To compare the risk effects of different antiplatelet therapies on gastrointestinal injury and summarize the endoscopic characteristics of gastrointestinal mucosal injury in the elderly. Methods The dyspepsia symptoms, gastrointestinal bleeding and endoscopic findings were retrospectively evaluated among 577 patients who received the antiplatelet therapy with aspirin and/or clopidogrel. Results The risk of dyspepsia symptoms and gastrointestinal bleeding was slightly higher in clopidogrel group than in aspirin group (both P＞0.05, x2=0.48, 0.72), and OR (95% CI): 1.10 (0.59-2.07) and 1.74 (0.48-6.33), for the risk of dyspepsia symptoms and gastrointestinal bleeding, respectively. In aspirin plus clopidogrel group, the risk of dyspepsia symptoms had no significant increase as compared with aspirin or clopidogrel group (x2=0.37, 0.03, for aspirin or clopidogrel group, respectively, both P＞0.05), but the risk of gastrointestinal bleeding was significantly higher than in aspirin group (x2=5.43, P＜0.05), OR (95% CI): 4.77 (1.15-19.79) and slightly higher than in clopidogrel group (P＞0.05). In this study, 57 patients received endoscopy and the detection rate of erosion or ulcer was 78.9%. Erosion (61.4%) was most in the gastric antrum; gastric ulcer (10.6%) located in gastric antrum and angle; duodenal ulcer (18.0%) located in bulb. In patients with dyspepsia symptoms erosion (70.5%), were most likely found but patients with gastrointestinal bleeding showed mainly ulcer (69.2%). Conclusions In the elderly the use of clopidogrel alone is not safer than low-dose aspirin and the combination would increase the risk of gastrointestinal bleeding. The detection rate of erosion or ulcer is high in patients with symptoms. Patients with dyspepsia symptoms most likely show erosion, but patients with gastrointestinal bleeding have mainly ulcer and complex ulcers more common.     

长期口服华法林钠患者冠状动脉支架术后抗栓治疗方案的分析

目的:讨论长期口服抗凝剂患者冠状动脉支架术后的抗栓治疗方案。方法:选择长期口服华法林钠,并在北京安贞医院接受冠状动脉造影(CA)和支架术(PCI)的患者,对临床资料进行回顾性分析,根据患者出院用药方案进行分组,比较组间基线特征,以及支架术后再梗死、死亡、脑梗死及出血等事件之间的差别。结果:符合要求的90例患者分为华法林钠+氯吡格雷+阿司匹林三联治疗组(A组)、华法林钠+氯吡格雷二联治疗组(B组)、阿司匹林+氯吡格雷二联治疗组(C组)。最常用治疗方案是停用华法林钠,联用阿司匹林和氯吡格雷。3个治疗组患者的再梗死、死亡、脑血管意外、严重出血及输血治疗等差异无统计学意义。结论:高危血栓栓塞风险患者冠状动脉支架术后应予三联治疗,密切监测凝血酶原时间(PT)和国际标准化比值(INR);而对于低危血栓栓塞风险的患者停用华法林钠,联用阿司匹林和氯吡格雷的治疗方案是可行的。本项调查观察样本量小,证据不够充分。针对不同患者制定相应的抗栓治疗方案,才能在获得良好抗栓疗效的同时减少出血事件。     

PCI术后双联抗血小板治疗致上消化道出血的预防与治疗

经皮冠状动脉介入术（PCI）后,接受阿司匹林和波立维双联抗血小板治疗已经成为预防支架内血栓形成的标准化治疗。在置入药物涂层支架（DES）后由于支架内皮化进程缓慢,服用双联抗血小板药物甚至要长于24个月。据统计,我国2008年进行PCI术患者约为16万,2009年预计将超过20万。由于行PCI术患者数日庞大,术后服用双联抗血小板治疗带来的副作用,     

Perioperative handling of patients on antiplatelet therapy with need for surgery

The widespread use of metal stents and drug-eluting stents has shown the extent to which patients with unstable coronary perfusion depend on antiplatelet drugs, and how their risk of late thrombosis depends on the long-term use of agents such as clopidogrel. It has also been shown that the risk of surgical bleeding, if antiplatelet drugs are continued, is lower than that of coronary thrombosis if they are withdrawn. Thus, except for low-risk settings, the practice of withdrawing antiplatelet drugs 5–10 days prior to surgical procedures should be changed. The following suggestions are meant to provide a guideline in this respect. Most of the current surgical procedures may be performed while on low-dose aspirin treatment. Except when bleeding may occur in closed spaces (e.g. intracranial surgery, spinal surgery in the medullary canal, surgery of the posterior chamber of the eye) or where excessive blood loss is expected, where only clopidogrel should be discontinued; in all other cases the surgical procedures should be carried out in the presence of dual antiplatelet agents (if prescribed). Aspirin may be discontinued only in subjects at low risk of thrombosis, and at high risk of intraoperative bleeding. Operations associated with an expected excessive blood loss should be postponed unless vital. When prescribed for acute coronary syndrome or during stent re-endothelialization, clopidogrel should not be discontinued before a noncardiac procedure. For elective procedures, surgery should be postponed until the end of the indication for clopidogrel. After the operation, clopidogrel should be resumed within the 12–24 h. Cardiac procedures should be postponed for at least 4 days after clopidogrel withdrawal. The thrombotic risk of preoperative withdrawal of antiplatelet drugs overwhelms the benefit of regional or neuraxial blockade. Antiplatelet treatment replacement by heparin or low-molecular weight heparin does not provide protection against the risk of coronary artery or stent thrombosis. Haemostasis requires that at least 20% of circulating platelets have a normal function. As the effects of antiplatelet agents are not reversible by other drugs, fresh platelets are the only manner to rapidly restore normal haemostasis. Aprotinin decreases postoperative bleeding and transfusion rates in patients undergoing CABG and on clopidogrel during the days preceding surgery.     

Combining warfarin and antiplatelet therapy after coronary stenting in the Global Registry of Acute Coronary Events: is it safe and effective to use just one antiplatelet agent?

AIMS: To identify factors associated with the use of single or dual antiplatelet therapy in patients prescribed warfarin following coronary stenting and to investigate whether single (aspirin or thienopyridine) vs. dual antiplatelet therapy plus warfarin leads to an excess of adverse outcomes. METHODS AND RESULTS: We analysed data from 800 patients with an acute coronary syndrome who underwent coronary stenting (130 patients received a drug-eluting stent) and were discharged on warfarin and either dual (n = 580) or single (n = 220) antiplatelet therapy. The use of single antiplatelet therapy was more common in Europe than in the USA (34 vs. 17%, P < 0.001). There was no difference in major bleeding in hospital or in 6-month mortality or myocardial infarction. In the single antiplatelet group, the use of either aspirin or thienopyridine (clopidogrel or ticlopidine) in combination with warfarin resulted in similar outcomes. CONCLUSION: Use of single vs. dual antiplatelet therapy and warfarin following stenting is common. In this observational study, there was no difference in mortality or myocardial infarction at 6 months; however, larger trials are needed to assert any firm recommendations.     

血栓弹力图在冠状动脉介入治疗患者抗血小板治疗中的应用研究

目的研究血栓弹力图（TEG）在评价抗血小板治疗疗效中的作用。方法纳入因冠心病接受PCI术后出现氯吡格雷抵抗患者50例,在接受氯吡格雷加量前后分别通过TEG检测血小板抑制率,对比两次TEG结果。结果强化抗血小板治疗后,所有患者TEG结果较前均显示血小板抑制率明显增加[（60.02±3.12）%vs.（21.26±3.68）%,P〈0.05],反应时间和凝固时间较前延长,凝血酶形成速度减慢,血凝块稳定性降低。结论 TEG能较准确地反映患者抗血小板状态,可作为抗血小板治疗评价指标。     

Knowledge, attitude and perception of antiplatelet therapy among dentists in Central Eastern Turkey

AIM:To survey the dentists in Central Eastern Turkey,testing their knowledge on coronary interventions and assessing perception of antecedent dual antiplatelet therapy.METHODS:Two hundred and ninety-eight dentists were surveyed face-to-face by completing questionnaires,including 16 structured questions focused on general knowledge of coronary stents,and assessing periprocedural practice with regard to antiplatelet therapy.RESULTS:All respondents were aware of such devices as coronary stents,but only one-third of the respondents knew the differences between a bare metal and a drug-eluting stent design,and associated vascularoutcomes.Awareness about stent thrombosis was limited to 34%,while consequences of interrupting antiplatelet therapy were known to only 30% of surveyed dentists.Importantly,the attitudes of surveyed respondents differed substantially depending on the location of their practice,where dentists working in the urban environment(population over 10 000) were more aware of antiplatelet recommendations when compared to their colleagues from the rural areas.CONCLUSION:Knowledge about coronary stents,associated clinical outcomes,and current guidelines with regard to surgical management of antecedent antiplatelet therapy in Central Eastern Turkey is inconsistent,and heavily dependent on the location of dental practice.Rural areas around the globe should be in a focus of continuous medical education to improve the quality of medical care.     

Predictive factors of therapeutic intervention in on-call endoscopy for suspected gastrointestinal bleeding

Background and Aims: Performing an endoscopy out of hours confer significant burdens on limited health-care resources. However, not all on-call endoscopies lead to therapeutic interventions. The purpose of the present study was to analyze predictive factors for performing therapeutic intervention in patients with suspected gastrointestinal bleeding.

Methods: We reviewed and analyzed electronic medical records regarding on-call endoscopy that were prospectively collected for quality control. The subjects were patients with suspected gastrointestinal bleeding who underwent on-call endoscopies at night, on weekends and on holidays between April 2013 and January 2017 in Seoul National University Bundang Hospital. To determine predictive factors for performing therapeutic intervention, the following variables were analyzed: symptoms, patient status, coexisting disease, laboratory findings and medications. To clarify the association between the likelihood of therapeutic intervention in on-call endoscopy and AIMS65 score, the included variables were divided by cutoffs.

Results: A total of 270 patients (male: 72.6%, mean age: 62.6 years) with suspected gastrointestinal bleeding had on-call endoscopies and 153 (56.7%) patients had therapeutic intervention. Gastroscopy, colonoscopy and both endoscopic techniques were performed in 215, 42 and 13 patients, respectively. In the multivariate analysis, hematemesis (p?p?=?.033; OR, 1.958) were correlated with performing therapeutic intervention in on-call endoscopy. AIMS65 score with a cutoff of 2 was associated with the likelihood of intervention (p?=?.043).

Conclusions: Hematemesis and prolonged PT-INR were predictive factors of therapeutic intervention when on-call endoscopy was performed in patients with suspected gastrointestinal bleeding.     

Duration of antiplatelet therapy cessation before coronary artery bypass surgery: Relation with platelet count

As of now, no study or data is available to determine the period of discontinuation of antiplatelet therapy and the timing of elective surgery in clopidogrel treated patients. The 2011 ACCF/AHA Guidelines have a Class-I recommendation for withdrawing clopidogrel for 5 days before elective coronary artery bypass grafting. However, 5 days period may not suit all patients as platelet count varies from 150 × 10⁹/L to 450 × 10⁹/L. Based on our retrospective data analysis, we have proposed a hypothesis to determine no of days of discontinuation of antiplatelet therapy while taking in consideration the basal count and life-span of platelets.