糖尿病ACS患者抗血小板治疗ppt课件

单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,糖尿病ACS患者抗血小板治疗,*,单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,糖尿病ACS患者抗血小板治疗,*,糖尿病,ACS,患者抗血小板治疗,首都医科大学附属北京友谊医院,心血管中心,李虹伟,糖尿病ACS患者抗血小板治疗,1,糖尿病ACS患者抗血小板治疗 首都医科大学附属北京友谊医院,NCEP-ATPIII:,糖尿病是心血管疾病的等危症,18.8%,3.5%,20.2%,45%,七年心肌梗死发生率,0,20,50,无糖尿病人群,2,型糖尿病人群,既往有心肌梗死人群,既往无心肌梗死人群,ATP3 final report,circulation,2002,Treat every diabetic as if they have already had a heart attack!,Haffner,N Engl. Med 1998;339:229,糖尿病ACS患者抗血小板治疗,2,NCEP-ATPIII: 糖尿病是心血管疾病的等危症18.8,中国心脏调查,34%,(420),66%,(814),(N=773),OGTT,European Heart Journal (2006) 27, 25732579,55.6%,(N=3513),65.9%,糖尿病ACS患者抗血小板治疗,3,中国心脏调查34%66%(N=773)OGTTEuropea,糖代谢状态,(STEMI+NSTEMI),12,0,(74.5%),41(25.5%),OGTT,(N=120),(N=161),52.5%,69.2%,Date in press,糖尿病ACS患者抗血小板治疗,4,糖代谢状态(STEMI+NSTEMI)120(74.5%)4,血小板在血栓形成中的作用,斑块破裂,血小板激活,激活的血小板聚集,血小板聚集,血栓形成,血管闭塞,血流中断,糖尿病ACS患者抗血小板治疗,5,血小板在血栓形成中的作用斑块破裂,激活的血小板聚集血小板聚集,GP IIb/IIIa,GP IIb/IIIa,血小板,5-羟色胺,肾上腺素,PAF,凝血酶,ADP,TXA,2,胶原,纤维蛋白原,GP IIb/IIIa拮抗剂,抵克力得,氯吡格雷,阿司匹林,腺苷,ADP,AMP,前列环素,潘生丁,西洛他唑,摄取,血小板活化途径与抗血小板药物的作用机理,血小板,抗血小板药物分类,糖尿病ACS患者抗血小板治疗,6,GP IIb/IIIaGP IIb/IIIa血小板5-羟色胺,一级预防,二级预防稳定,阿司匹林,阿司匹林禁忌时氯吡格雷替代,ACS/PCI,阿司匹林,+,氯吡格雷,PCI,阿司匹林,+GP,，阿司匹林,+,氯吡格雷,+GP,PAD,西洛他唑缓解症状,卒中,/TIA,阿司匹林,+,缓释潘生丁,氯吡格雷,抗血小板药物一、二级预防,阿司匹林是唯一推荐用于一、二级预防的药物,二级预防,急性期,ACS,糖尿病ACS患者抗血小板治疗,7,一级预防二级预防稳定阿司匹林阿司匹林禁忌时氯吡格雷替代A,*,糖尿病亚组,RR 95%CI P,脑卒中,0.83 0.69-0.99 0.04,脑梗死,0.76 0.63-0.93 0.009,脑卒中*,0.46 0.25-0.85 0.01,脑梗死 *,0.42 0.22-0.82 0.01,女性健康研究,(WHS),阿司匹林显著降低女性脑卒中,/,脑梗死危险,利于阿司匹林,利于安慰剂,1,0,0.5,女性健康研究, N=39876,ASA100mg/,隔日,vs. Placebo,10yrs,Womens Health Study, N Engl J Med 2005, 352:1295,糖尿病ACS患者抗血小板治疗,8,*糖尿病亚组 RR 95%C,Physicians Health Study, N Engl J Med 1989,321:129-35,首次致死性,MI,66,P=0.007,10,20,30,致死性心肌梗死病例数,26,10,安慰剂组 阿司匹林组,首次,MI,44,P0.00001,100,200,250,心肌梗死病例数,239,139,安慰剂组 阿司匹林组,10.1,4,5,10,15,安慰剂组,阿司匹林组,糖尿病组首次,MI,61%,糖尿病亚组,PHS, N=22071,ASA325mg/,隔日,vs. Placebo,，,5yrs,内科医生健康研究,Physicians Health Study (PHS),心肌梗死发病率（,%,）,糖尿病ACS患者抗血小板治疗,9,Physicians Health Study, N En,2007,年,ADA/AHA,联合指南一级预防推荐,2,型糖尿病伴以下任一高危因素者，应用阿司匹林,75162mg/,日一级预防心脑血管疾病,(A),年龄,40,岁 吸烟, 肥胖 高血压, 血脂异常 蛋白尿, 冠心病家族史,糖尿病ACS患者抗血小板治疗,10,2007年ADA/AHA联合指南一级预防推荐2型糖尿病伴以下,阿司匹林对,AMI,患者的绝对效益,糖尿病ACS患者抗血小板治疗,11,阿司匹林对AMI患者的绝对效益糖尿病ACS患者抗血小板治疗1,阿司匹林对,ACS,患者的绝对效益,糖尿病ACS患者抗血小板治疗,12,阿司匹林对ACS患者的绝对效益糖尿病ACS患者抗血小板治疗1,CAD progression and/orworse outcomes post-PCI,Roffi M, Topol EJ.,Eur Heart J,. 2004;25:190-8.,RAGE = receptor for advanced glycation end-products (AGE)TSP-1 = thrombospondin-1,糖尿病患者促,CAD,的原因,Inflammation,hsCRP, IL-6. VCAM-1, ICAM-1, P-selectin, sCD40L, TNF-, TSP-1,Prothrombotic state,GP IIb/IIIa receptors,Platelet factor 4,Fibrinogen, TF, vWf,PAI-1,Protein C,Associated conditions,Renal dysfunction,LV dysfunction,Peripheral vascular disease,Atherosclerotic burden,Diffuse disease,Multivessel disease,Negative remodeling,Restenosis,Hyperinsulinemia,RAGE/AGE,PPAR- modulation,TSP-1,Endothelial dysfunction,Hyperglycemia,Free fatty acids,Insulin resistance,RAGE/AGE,Dyslipidemia,糖尿病ACS患者抗血小板治疗,13,CAD progression and/orworse o,Colwell JA, Nesto RW.,Diabetes Care,. 2003;26:2181-8.,糖尿病患者的血小板功能变化,膜,Ca,+2,和,Mg,+2,代谢障碍,花生四烯酸代谢,TXA,2,合成,前列腺环素,NO,生成,抗氧化能力,激活依赖的粘联分子,(eg, GP IIb/IIIa, P-selectin),这些变化导致糖尿病患者聚集和粘联作用增加,糖尿病ACS患者抗血小板治疗,14,Colwell JA, Nesto RW. Diabetes,合并糖尿病的,CAD,患者,Thromb Haemost 2008; 100: 7682,血小板聚集增强,氯吡格雷抗血小板聚集作用下降,糖尿病ACS患者抗血小板治疗,15,合并糖尿病的CAD患者Thromb Haemost 2008,TRITON-TIMI 38,(,TR,ial to Assess,I,mprovement in,T,herapeutic,O,utcomes by Optimizing Platelet Inhibitio,N,with Prasugrel-Thrombolysis in Myocardial Infarction),Prasugrel,为第三代抑制,ADP,活化药物,与氯吡格雷类似,有研究显示其抗血小板作用强于标准剂量或高剂量的氯吡格雷,TIMI 38,共入选,ACS,患者,13,457,例,Circulation 2008;118:1626,糖尿病ACS患者抗血小板治疗,16,TRITON-TIMI 38(TRial to Asses,TRITON-TIMI38:,结果,(1),Circulation 2008;118:1626,糖尿病ACS患者抗血小板治疗,17,TRITON-TIMI38: 结果 (1)Circula,Circulation 2008;118:1626,TRITON-TIMI38:,结果,(2),糖尿病ACS患者抗血小板治疗,18,Circulation 2008;118:1626TRITO,Circulation 2008;118:1626,TRITON-TIMI38:,结果,(3),糖尿病ACS患者抗血小板治疗,19,Circulation 2008;118:1626TRITO,Circulation 2008;118:1626,TRITON-TIMI38:,结果,(4),糖尿病ACS患者抗血小板治疗,20,Circulation 2008;118:1626TRITO,Am Heart J 2008;156:S3-S9,糖尿病影响抗血小板的变异性,糖尿病ACS患者抗血小板治疗,21,Am Heart J 2008;156:S3-S9糖尿病影响,Alexander KP et al.,JAMA.,2005;294:3108-16.,影响出血不良反应的主要因素,Patients vulnerable to overdosing,Older age(65 years),Female,Diabetes,CHF,Low bodyweight,Renalinsufficiency,糖尿病ACS患者抗血小板治疗,22,Alexander KP et al. JAMA. 2005,谢 谢,!,糖尿病ACS患者抗血小板治疗,23,谢 谢!糖尿病ACS患者抗血小板治疗23,