Acute coronary syndrome antithrombotic treatment
Coronary Atherosclerosis is a chronic inflammatory disease. In the course of its long, often due to plaque rupture or erosion caused partial thrombosis, resulting in the complete coronary / or partial obstruction, the clinical manifestations of acute coronary syndrome. According to basic and clinical pathology, such as ECG performance, we can be divided into acute coronary syndrome ST-segment elevation acute coronary syndromes and non-ST-segment elevation acute coronary syndrome two categories. As in recent years on the atherosclerotic disease awareness of the progress of antithrombotic treatment of acute coronary syndrome has made considerable progress.
ST-segment elevation acute coronary syndrome is the best means of reperfusion therapy
ST-segment elevation acute coronary syndrome is the pathological basis of plaque rupture or lead to ulcers local platelet activation and thrombosis, resulting in a branch or completely occluded coronary artery. At present substantial clinical data, quickly and effectively to reperfusion therapy is the best treatment. If the reception in the first 90 minutes of the treatment experienced by the group, percutaneous coronary intervention (PCI) should be the preferred method if not urgent PCI treatment, and no contraindications, while thrombolytic treatment is an effective reperfusion therapy. CLARITY-TIMI28 study shows that during thrombolytic therapy on the basis of patients given 300 mg loading dose of clopidogrel followed by 75 mg per day of the maintenance, it can further reduce the infarct-related artery occlusion rate (OR = 0.64,95 95% CI = 0.53 to 0.76, P <0.001) (Figure 1); through active antiplatelet therapy, the patient died 30 days before the myocardial infarction and ischemia revascularization lead to the relative risk can be reduced by 20% (Figure 2 ), without increasing the relative risk of hemorrhage.
PCI-CLARITY major evaluation of acute myocardial infarction patients receive interventional treatment benefit from the use of clopidogrel, clopidogrel pretreatment can reduce by 30 days in patients with cardiac death, myocardial infarction, or stroke risk (OR = 0.54,95 95% CI = 0.38 to 0.85, P = 0.008).
COMMIT-CCS2 further verify the efficacy of clopidogrel, regardless of whether the patient received thrombolytic therapy, given 75 mg / day of clopidogrel make follow-up period of 30 days with the death of 7% relative risk reduction (P = 0.003), death, myocardial infarction, stroke, and then the relative risk of 9% (P = 0.002) (Figure 3).
Plavix anti-platelet treatment, patients did not increase the risk of hemorrhagic stroke, the risk of ischemic stroke is decreasing. Based on the above clinical findings of the study, some experts in response to reperfusion in acute myocardial infarction treatment strategy: all STEMI patients, regardless of the subsequent acceptance of thrombolytic therapy or percutaneous interventional treatment should first accept the clopidogrel 300 mg + A Division bhp-lam as the initial treatment.
In thrombolytic therapy, heparin can reduce the infarct-related artery occlusion rate again, thrombolytic therapy is the standard adjuvant therapy one. However, the use of unfractionated heparin, it is necessary to adjust monitoring APTT heparin dosage, physicians and patients are to a certain inconvenience. Low molecular weight heparin pharmacokinetics of a more stable, do not use monitoring. ASSENT Ⅲ study TNK as a thrombolytic agent, compared unfractionated heparin, as well as Afghanistan Enoxaparin infliximab as adjuvant treatment of the safety and effectiveness. These results indicate that: Compared with unfractionated heparin, Enoxaparin can reduce the use of patients with acute myocardial infarction after thrombolytic therapy during hospitalization TNK to stem the risk, and the risk of hemorrhage and unfractionated heparin considerable. Enoxaparin superiority completed in 2006, an international multi-center randomized clinical study ExTRACT TIMI-25 study has been further verified.
Non-ST-segment elevation acute coronary syndrome is the main treatment anticoagulant, anti-platelet, anti-ischemic and revascularization
Non-ST-segment elevation acute coronary syndrome is the pathological basis of partial platelet thrombus formation, makes vascular lumen of the small-vessel occlusion and distal embolization, with focal myocardial necrosis. Non-ST-segment elevation acute coronary syndrome, the current treatment mainly concentrated in four areas: anticoagulant, anti-platelet, anti-ischemic and revascularization therapy. A number of clinical research meta-analysis showed: For non-ST-segment elevation acute coronary syndrome patients, Enoxaparin therapeutic effect than unfractionated heparin, and the risk of bleeding is both. Enoxaparin treatment in the superiority of one-year follow-up period persisted. Non-ST-segment elevation acute coronary syndrome patients receiving PCI treatment, intravenous use of Enoxaparin (0.5 mg / kg or 0.75 mg / kg) and the effect of heparin quite ordinary, and better security (Figure 4 ).
The direct thrombin inhibitor A meta-analysis of clinical studies showed that: Compared with unfractionated heparin, recombinant hirudin (than cutting LU), and the effect of heparin quite ordinary, such as the elderly and renal dysfunction in patients with high-risk, recombinant hirudin the effect of better, and the risk of hemorrhage was significantly lower than unfractionated heparin.
The latest information is the 2006 ACC EXTRACT TIMI25 conference to announce the results. In 20,506 cases of acute myocardial infarction patients in the group with Enoxaparin unfractionated heparin group died compared with 30 days / non-fatal myocardial infarction reduced the relative risk of 17% (Figure 5).
Enoxaparin benefits of the treatment in the first 48 hours after treatment has been achieved statistically significant (P <0.001). Pre-defined in the various subgroups, Enoxaparin show the same effect. PCI received 4,676 cases of patients with clinical outcome, compared with unfractionated heparin, Enoxaparin 30 days to reduce deaths / non-fatal myocardial infarction risk by 23%, without increasing the risk of severe bleeding.
Clopidogrel in patients with acute coronary syndrome treatment of superiority
Based on non-ST-segment elevation acute coronary syndrome pathophysiological mechanisms, antiplatelet therapy in the treatment of a very important one. At present, anti-platelet drugs, including treatment of cyclooxygenase inhibitor (aspirin), ADP receptor antagonist, thienopyridine derivatives (ticlopidine, clopidogrel), and platelet glycoprotein Ⅱ b / Ⅲ a subject - antagonist. On the meta-analysis of aspirin study showed that: Compared with placebo, aspirin can reduce death or myocardial infarction in patients with the risk. The best use of aspirin dose range is 75 to 150 mg, less than 75 mg of aspirin no clear effect, more than 75 mg of aspirin can increase the effect, but significantly increased the risk of bleeding. The platelet glycoprotein Ⅱ b / Ⅲ a receptor antagonists of the current mixed results. Overall results of glycoprotein receptor antagonist can reduce the patients died during the follow-up of 30 days and the risk of myocardial infarction (OR = 0.91,0.84 ~ 0.98). Different molecular weight glycoproteins Ⅱ b / Ⅲ a receptor antagonist effect is not consistent: the low molecular weight tirofiban and Eptifibatide more obvious effects, and high molecular weight classes and non-Lamy A infliximab in the show outcomes. Different patients glycoprotein Ⅱ b / Ⅲ a receptor antagonist treatment benefit is also not the same, troponin-positive patients receiving intervention or bypass surgery patients and patients with diabetes benefit more. Currently, non-ST-segment elevation acute coronary syndrome treatment, Plavix position is very important. CURE study, a single treatment with aspirin compared to clopidogrel (300 mg loading dose +75 mg / day to maintain) and the use of aspirin, can reduce patients with a follow-up period of cardiovascular death, myocardial infarction, and the risk of stroke (4.3% vs 5.4%), 1-year follow-up period, the end of the incident with the relative risk by 20 per cent (9.5 per cent of the 11.8%, P = 0.009) (Figure 6).
Whether conservative accept medical treatment, percutaneous interventional treatment or coronary artery bypass surgery patients can benefit from clopidogrel treatment. For patients receiving bypass surgery, can be suspended if the preoperative Clopidogrel on the 5th above, the risk of bleeding and not increased significantly. CURE study long-term follow-up results suggest that long-term use of clopidogrel in patients with treatment can further benefit in a month after continued use of Plavix patients can further reduce the risk of cardiovascular events (OR = 0.82,95% CI 0.70 to 0.95 , P = 0.009). CREDO study showed, for the need for interventional treatment of patients, the use of Plavix could cardiovascular events in patients with a year of relative risk reduction 27% (11.5% to 8.5%, P = 0.002). Further analysis showed that the use of clopidogrel in the 13 hours after intervention, the patient can benefit from the more obvious. CREDO study also demonstrates the long-term treatment of the effect of clopidogrel.
Coronary Atherosclerosis is a chronic inflammatory disease. In the course of its long, often due to plaque rupture or erosion caused partial thrombosis, resulting in the complete coronary / or partial obstruction, the clinical manifestations of acute coronary syndrome. According to basic and clinical pathology, such as ECG performance, we can be divided into acute coronary syndrome ST-segment elevation acute coronary syndromes and non-ST-segment elevation acute coronary syndrome two categories. As in recent years on the atherosclerotic disease awareness of the progress of antithrombotic treatment of acute coronary syndrome has made considerable progress.
ST-segment elevation acute coronary syndrome is the best means of reperfusion therapy
ST-segment elevation acute coronary syndrome is the pathological basis of plaque rupture or lead to ulcers local platelet activation and thrombosis, resulting in a branch or completely occluded coronary artery. At present substantial clinical data, quickly and effectively to reperfusion therapy is the best treatment. If the reception in the first 90 minutes of the treatment experienced by the group, percutaneous coronary intervention (PCI) should be the preferred method if not urgent PCI treatment, and no contraindications, while thrombolytic treatment is an effective reperfusion therapy. CLARITY-TIMI28 study shows that during thrombolytic therapy on the basis of patients given 300 mg loading dose of clopidogrel followed by 75 mg per day of the maintenance, it can further reduce the infarct-related artery occlusion rate (OR = 0.64,95 95% CI = 0.53 to 0.76, P <0.001) (Figure 1); through active antiplatelet therapy, the patient died 30 days before the myocardial infarction and ischemia revascularization lead to the relative risk can be reduced by 20% (Figure 2 ), without increasing the relative risk of hemorrhage.
PCI-CLARITY major evaluation of acute myocardial infarction patients receive interventional treatment benefit from the use of clopidogrel, clopidogrel pretreatment can reduce by 30 days in patients with cardiac death, myocardial infarction, or stroke risk (OR = 0.54,95 95% CI = 0.38 to 0.85, P = 0.008).
COMMIT-CCS2 further verify the efficacy of clopidogrel, regardless of whether the patient received thrombolytic therapy, given 75 mg / day of clopidogrel make follow-up period of 30 days with the death of 7% relative risk reduction (P = 0.003), death, myocardial infarction, stroke, and then the relative risk of 9% (P = 0.002) (Figure 3).
Plavix anti-platelet treatment, patients did not increase the risk of hemorrhagic stroke, the risk of ischemic stroke is decreasing. Based on the above clinical findings of the study, some experts in response to reperfusion in acute myocardial infarction treatment strategy: all STEMI patients, regardless of the subsequent acceptance of thrombolytic therapy or percutaneous interventional treatment should first accept the clopidogrel 300 mg + A Division bhp-lam as the initial treatment.
In thrombolytic therapy, heparin can reduce the infarct-related artery occlusion rate again, thrombolytic therapy is the standard adjuvant therapy one. However, the use of unfractionated heparin, it is necessary to adjust monitoring APTT heparin dosage, physicians and patients are to a certain inconvenience. Low molecular weight heparin pharmacokinetics of a more stable, do not use monitoring. ASSENT Ⅲ study TNK as a thrombolytic agent, compared unfractionated heparin, as well as Afghanistan Enoxaparin infliximab as adjuvant treatment of the safety and effectiveness. These results indicate that: Compared with unfractionated heparin, Enoxaparin can reduce the use of patients with acute myocardial infarction after thrombolytic therapy during hospitalization TNK to stem the risk, and the risk of hemorrhage and unfractionated heparin considerable. Enoxaparin superiority completed in 2006, an international multi-center randomized clinical study ExTRACT TIMI-25 study has been further verified.
Non-ST-segment elevation acute coronary syndrome is the main treatment anticoagulant, anti-platelet, anti-ischemic and revascularization
Non-ST-segment elevation acute coronary syndrome is the pathological basis of partial platelet thrombus formation, makes vascular lumen of the small-vessel occlusion and distal embolization, with focal myocardial necrosis. Non-ST-segment elevation acute coronary syndrome, the current treatment mainly concentrated in four areas: anticoagulant, anti-platelet, anti-ischemic and revascularization therapy. A number of clinical research meta-analysis showed: For non-ST-segment elevation acute coronary syndrome patients, Enoxaparin therapeutic effect than unfractionated heparin, and the risk of bleeding is both. Enoxaparin treatment in the superiority of one-year follow-up period persisted. Non-ST-segment elevation acute coronary syndrome patients receiving PCI treatment, intravenous use of Enoxaparin (0.5 mg / kg or 0.75 mg / kg) and the effect of heparin quite ordinary, and better security (Figure 4 ).
The direct thrombin inhibitor A meta-analysis of clinical studies showed that: Compared with unfractionated heparin, recombinant hirudin (than cutting LU), and the effect of heparin quite ordinary, such as the elderly and renal dysfunction in patients with high-risk, recombinant hirudin the effect of better, and the risk of hemorrhage was significantly lower than unfractionated heparin.
The latest information is the 2006 ACC EXTRACT TIMI25 conference to announce the results. In 20,506 cases of acute myocardial infarction patients in the group with Enoxaparin unfractionated heparin group died compared with 30 days / non-fatal myocardial infarction reduced the relative risk of 17% (Figure 5).
Enoxaparin benefits of the treatment in the first 48 hours after treatment has been achieved statistically significant (P <0.001). Pre-defined in the various subgroups, Enoxaparin show the same effect. PCI received 4,676 cases of patients with clinical outcome, compared with unfractionated heparin, Enoxaparin 30 days to reduce deaths / non-fatal myocardial infarction risk by 23%, without increasing the risk of severe bleeding.
Clopidogrel in patients with acute coronary syndrome treatment of superiority
Based on non-ST-segment elevation acute coronary syndrome pathophysiological mechanisms, antiplatelet therapy in the treatment of a very important one. At present, anti-platelet drugs, including treatment of cyclooxygenase inhibitor (aspirin), ADP receptor antagonist, thienopyridine derivatives (ticlopidine, clopidogrel), and platelet glycoprotein Ⅱ b / Ⅲ a subject - antagonist. On the meta-analysis of aspirin study showed that: Compared with placebo, aspirin can reduce death or myocardial infarction in patients with the risk. The best use of aspirin dose range is 75 to 150 mg, less than 75 mg of aspirin no clear effect, more than 75 mg of aspirin can increase the effect, but significantly increased the risk of bleeding. The platelet glycoprotein Ⅱ b / Ⅲ a receptor antagonists of the current mixed results. Overall results of glycoprotein receptor antagonist can reduce the patients died during the follow-up of 30 days and the risk of myocardial infarction (OR = 0.91,0.84 ~ 0.98). Different molecular weight glycoproteins Ⅱ b / Ⅲ a receptor antagonist effect is not consistent: the low molecular weight tirofiban and Eptifibatide more obvious effects, and high molecular weight classes and non-Lamy A infliximab in the show outcomes. Different patients glycoprotein Ⅱ b / Ⅲ a receptor antagonist treatment benefit is also not the same, troponin-positive patients receiving intervention or bypass surgery patients and patients with diabetes benefit more. Currently, non-ST-segment elevation acute coronary syndrome treatment, Plavix position is very important. CURE study, a single treatment with aspirin compared to clopidogrel (300 mg loading dose +75 mg / day to maintain) and the use of aspirin, can reduce patients with a follow-up period of cardiovascular death, myocardial infarction, and the risk of stroke (4.3% vs 5.4%), 1-year follow-up period, the end of the incident with the relative risk by 20 per cent (9.5 per cent of the 11.8%, P = 0.009) (Figure 6).
Whether conservative accept medical treatment, percutaneous interventional treatment or coronary artery bypass surgery patients can benefit from clopidogrel treatment. For patients receiving bypass surgery, can be suspended if the preoperative Clopidogrel on the 5th above, the risk of bleeding and not increased significantly. CURE study long-term follow-up results suggest that long-term use of clopidogrel in patients with treatment can further benefit in a month after continued use of Plavix patients can further reduce the risk of cardiovascular events (OR = 0.82,95% CI 0.70 to 0.95 , P = 0.009). CREDO study showed, for the need for interventional treatment of patients, the use of Plavix could cardiovascular events in patients with a year of relative risk reduction 27% (11.5% to 8.5%, P = 0.002). Further analysis showed that the use of clopidogrel in the 13 hours after intervention, the patient can benefit from the more obvious. CREDO study also demonstrates the long-term treatment of the effect of clopidogrel.