冠状动脉扩张合并房颤病例分享

*,*,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,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,*,*,病例分享,心内科,1,病史情况,患者男性，,68,岁，体重,80KG,，,主诉：因“反复胸闷、胸痛,3,年，再发加重,3,天” 入院。,2,现病史,患者,2012,年因急性心梗行冠脉造影检查及,PCI,术，共植入支架,3,枚。,3,天前无诱因再发胸闷、胸痛，伴大汗，含服“硝酸甘油”无缓解，院外诊断为急性下壁心梗，当地医院予“尿激酶”行溶栓治疗仍有胸痛症状，转入我科。,3,既往病史,既往史：高血压病史,20,余年，规律服用“安博诺,1,片,qd,、倍他乐克缓释片,1,片,qd”,治疗，血压控制可；,2,型糖尿病病史,10,余年，规律注射诺和灵,30R,胰岛素控制，血糖控制在空腹，糖化血红蛋白,4.41%,。,个人史：抽烟,30,余年，戒断,3,年。,4,入院查体,入院检查：,Bp143/91mmHg,，氧饱和度,94%,（鼻导管吸氧），双肺底闻及湿性啰音。心浊音界向左侧扩大，心率,86,次,/,分，节律不齐，第一心音强弱不等，无杂音，双下肢不肿。,5,入院心电图,6,入院心电图,入院床旁心电图示：房颤；频发室早二联律，,II,、,III,、,avF,、,V4-V6,导联,ST-T,波。,7,实验室检查,8,肾功、电解质,9,BNP,10,心脏彩超,11,入院诊断：,1、冠心病 急性下壁心梗，心脏扩大，房颤心律，频发室早，心功能,2,级（,KILLIP,分级）,2,、高血压病,3,级 极高危组,3,、,2,型糖尿病,12,术前用药,当地医院给予阿司匹林,300+100mg qd,，氯吡格雷,300+75mg qd,患者入院后仍有胸闷、胸痛症状，入院予替格瑞洛,180mg po st,，急诊行冠脉造影检查。,13,7,月,1,日造影过程,JR4.0,造影管行右冠造影示：,RCA,全程弥漫性病变，近段支架影，支架近段,30-40%,狭窄，中远段多处瘤样扩张；,TIMI,血流,2,级；,14,JL3.5,行左冠造影,: LM,正常，,LCX,全程弥漫性病变，近段,30%,狭窄，中段瘤样扩张并,90%,狭窄，,TIMI,血流,3-,级,15,LAD,近段见支架影，支架内,30-40%,狭窄，,D1,近中段多处瘤样扩张并,50-70,狭窄，,TIMI,血流,2,级，中间支近段,90%,狭窄，,TIMI,血流,2-,级，,16,17,治疗策略思考,患者,2,型糖尿病合并三支血管瘤样扩张弥漫性病变，且合并支架内在狭窄，急诊造影提示：罪犯血管,TIMI,血流,3-,级，提示溶栓治疗成功，遂予以强化抗栓治疗，择期再次复查造影。,18,CAG,后用药,依诺肝素,4000iu q12h,（,5,天）,阿司匹林肠溶片,100mg qd,替格瑞洛,90mg bid,瑞舒伐他汀,10mg qn,厄贝沙坦氢氯噻嗪片,150mg qd,，,美托洛尔缓释片,47.5mg qd,19,7,月,8,日造影、手术过程,20,7,月,8,日,XB3.5,指引导管到位后，以,SOFT,导丝通过,LCX,病变达远端，以,Runthrough,导丝对,OM1,保护，,2.5X20mm,球囊预扩张,21,植入,4.5X24mm,支架,22,造影示支架中段残余狭窄,30%,23,以,5.0X15,球囊后扩,24,再次造影,25,冠脉内注射替罗非班，并用血栓抽吸导管抽吸,26,复查造影,27,术后的抗栓治疗策略,患者心梗,PCI,术后合并心房纤颤再加三支血管弥漫性瘤样扩张病变，该如何强化抗栓治疗？,28,CRUSADE,出血评分,本患者评分：,38,分 风险分级：中危,参数,范围,计分,参数,范围,计分,基线红细胞压积,(%),51.4,15-30,30-60,60-90,90-120,120,39,35,28,17,7,0,心率,(bpm),86,70,71-80,81-90,91-100,101-110,111-120, 121,0,1,3,6,8,10,11,收缩压,(mm Hg),143,90,91-100,101-120,121-180,181-200, 201,10,8,5,1,3,5,心力衰竭的表现,无,No,Yes,0,7,血管疾病病史,无,No,Yes,0,6,性别,男,Male,Female,0,8,糖尿病,有,No,Yes,0,6,肌酐清除率,(mL/min),：,Ccr=,（,140-,年龄）,X,体重（,Kg,）,/0.818XScr(umol/L),女性再乘,0.85,。,Scr-,血肌酐。,成人正常值：,80-120ml/min,。,CRUSADE,出血评分结果分为,不同的危险组,风险,最低分,最高分,出血率,非常低,1,20,3.1%,低,21,30,5.5%,中等,31,40,8.6%,高,41,50,11.9%,非常高,51,91,19.5%,29,CRACE,评分表,Killip,分级,得,分,收缩压,（,mmHg,）,得,分,心率,（次,/,分）,得,分,年龄,（岁）,得,分,CK,值,（,mg/dl,）,得,分,危险因素,得,分,I,0,80,58,50,0,30,0,0-0.39,1,院前心跳骤停,39,II,20,80-99,53,50-69,3,30-39,8,0.4-0.79,4,ST,段下降,28,III,39,100-119,43,70-89,9,40-49,25,0.8-1.19,7,心肌酶升高,14,IV,59,120-139,34,90-109,15,50-59,41,1.2-1.59,10,140-159,24,110-149,24,60-69,58,1.6-1.99,13,160-199,10,150-199,38,70-79,75,2.0-3.99,21,200,0,200,46,80,91,4.0,28,99,分以下为低危，,100-200,分为高危，,201,分以上为极高危,合计：,187,分。,为高危缺血患者,30,冠脉扩张定义、诊疗方案,1,、心外膜下冠状动脉的局限性或弥漫性扩张，超过邻近正常血管的倍，称为冠状动脉扩张,长度,7mm,。,2,、超过邻近正常血管的,2.0,倍，则称为冠状动脉瘤或瘤样扩张，长度一般,65,岁）,1,分,1,分,D,药物或嗜酒（各,1,分）,37,术后治疗方案思考,患者,68,岁男性，基础高血压病、,2,型糖尿病、房颤，肾功能不全，造影提示多支血管存在瘤样扩张；,GRACE,缺血评分,187,（高危组），,CRUSADE,出血评分为,38,分（中危组）；,CHADS2,评分,3,分；,HAS-BLED,评分,3,分,患者血栓风险及出血风险评估后，术后抗栓治疗如何选择,38,PCI,后抗栓用药,依诺肝素,4000iu q12h,（,5,天）,阿司匹林肠溶片,100mg qd,替格瑞洛,90mg bid,瑞舒伐他汀,10mg qn,盐酸替罗非班,5ml/h,，持续,24h,39,讨论,该患者抗栓治疗策略？,40,NSTE-ACS,合并房颤患者的抗栓药物管理,Roffi M, et al. European Heart Journal. doi:10.1093/eurheartj/ehv320,NSTE-ACS,合并非瓣膜性房颤,PCI,药物治疗,/CABG,管理策略,出血风险,PCI/ACS,后时间,低,-,中危,(,如，,HAS-BLED=0-2),高危,(,如，,HAS-BLED3),0,4,周,6,月,12,月,终生,口服抗凝药,(VKA,或,NOAC),阿司匹林,75-100mg/d,氯吡格雷,75mg/d,三联,三联,/,双抗,双抗,双抗,双抗,单药治疗,41,需长期口服抗凝治疗（如房颤）患者的抗血小板推荐,需长期口服抗凝药物且植入冠脉支架患者的抗血小板推荐,推荐级别,证据水平,NSTE-ACS,合并房颤且,CHA,2,DS,2,-VASc,评分,1,分（男性）或,2,分（女性）的患者，冠脉植入支架后，应考虑使用包含新型,P2Y12,抑制剂的双抗治疗替代三联疗法。,Following coronary stenting, DAPT including new P2Y12 inhibitors should be considered as an alternative to triple therapy for patients with NSTE-ACS and atrial fibrillation with a CHA2DS2-VASc score of 1 (in males) or 2 (in females).,IIa,C,如果出血危险低（,HAS-BLED2,），口服抗凝药、阿司匹林,75-100mg/d,、氯吡格雷,75mg/d,的三联疗法应考虑治疗,6,个月，随后使用口服抗凝药和阿司匹林,75-100mg/d,或氯吡格雷,75mg/d,持续治疗达,12,个月。,If at low bleeding risk (HAS-BLED 2), triple therapy with OAC, aspirin (75100 mg/day) and clopidogrel 75 mg/day should be considered for 6 months, followed by OAC and aspirin 75100 mg/day or clopidogrel (75 mg/day) continued up to 12 months.,IIa,C,如果出血危险高（,HAS-BLED3,），无论使用支架类型（,BMS,或新一代,DES,），口服抗凝药、阿司匹林,75-100mg/d,、氯吡格雷,75mg/d,的三联疗法应考虑治疗,1,个月，随后使用口服抗凝药和阿司匹林,75-100mg/d,或氯吡格雷,75mg/d,持续治疗达,12,个月。,If at high bleeding risk (HAS-BLED 3),triple therapy with OAC, aspirin (75100 mg/day) and clopidogrel 75 mg/day should be considered for a duration of 1 month, followed by OAC and aspirin 75100 mg/day or clopidogrel (75 mg/day) continued up to 12 months irrespective of the stent type (BMS or new-generation DES).,IIa,C,某些特殊患者（,HAS-BLED3,和支架血栓风险低），口服抗凝药联合氯吡格雷,75mg/d,的双联治疗可考虑替代三联疗法。,Dual therapy with OAC and clopidogrel 75 mg/day may be considered as an alternative to triple antithrombotic therapy in selected patients (HAS-BLED 3 and low risk of stent thrombosis).,IIb,B,不推荐替格瑞洛或普拉格雷用于三联疗法。,The use of ticagrelor or prasugrel as part of triple therapy is not recommended.,III,C,Roffi M,et al.European Heart Journal,2015;doi:10.1093/eurheartj/ehv320,42,出院带药,阿司匹林,100mg qd,替格瑞洛片,90mg bid,，,瑞舒伐他汀片,10mg qd,，,厄贝沙坦氢氯噻嗪片,150mg qd,，,美托洛尔缓释片,47.5mg qd,诺和灵,30R,胰岛素控制血糖,43,Thank You !,44,