TEG技術與檢驗科及應用

1、1會計學TEG技術與檢驗科及應用技術與檢驗科及應用摘自：血栓與止血試驗診斷的現狀與發(fā)展；摘自：血栓與止血試驗診斷的現狀與發(fā)展；301醫(yī)院；從玉隆等，醫(yī)院；從玉隆等，2002，9；中華檢驗醫(yī)學雜志；中華檢驗醫(yī)學雜志 Interactive外傷外傷“暴露暴露”初始的凝血酶反應初始的凝血酶反應 膠原vWFVVVVVV血塊強度血塊強度初始的凝血TF血流表面血流表面第二階段凝血第三階段凝血出血血栓藥理學藥理學感染炎癥感染炎癥機械原因機械原因病理性疾病病理性疾病初始凝血初始凝血第二階段第二階段凝血凝血第三階段第三階段凝血凝血PT: 10-12 secPT: 10-12 secINR: 0.9-1.1 IN

2、R: 0.9-1.1 aPTT: 28-34 sec aPTT: 28-34 sec /clinpath/modules/coags/coag.htmAccessed 7/29/06INR = international normalized ratio初始凝血初始凝血第二階段第二階段凝血凝血第三階段第三階段凝血凝血IIa兩個獨立的通道兩個獨立的通道溫度顯示溫度顯示 & 控制控制電腦數據收集電腦數據收集 & 儲存儲存0.36ml毫升全血毫升全血試試杯杯感應針感應針電磁場電磁場普通檢測凝血全過程描記：判斷低凝高凝纖

3、溶亢進肝素酶檢測監(jiān)測肝素作用：普通肝素低分子肝素類肝素物質血小板圖檢測檢測不同的抗血小板藥物的療效，為個性化抗血小板治療提供科學依據R凝血時間IIa 生成的纖維蛋白形成凝血旁路參數r凝血狀況凝血成分低凝高凝 R (min) R (min) K (min) a (deg) K (min) a (deg) MA MA血塊穩(wěn)定性血塊強度的減弱纖維溶解血塊速率纖維蛋白X-聯(lián)結纖維蛋白血小板凝血旁路血小板Ka最大血塊強度（血小板 纖維蛋白原)相互作用血小板 (80%)纖維蛋白原(20%)MA30 minLY30EPLLY30 7.5%EPL 15%N/ACI功能紊亂4-8 min47- 741-4 mi

4、n55-73 mm-3.0 3.00-8%0-15%凝血時間凝血時間R是反應從凝血系統(tǒng)啟動直到纖維蛋白凝塊形成之間的一段潛伏期。血塊動力血塊動力K評估血凝塊強度達到某20 mm時的時間，主要反應纖維蛋白原的功能和水平。Alpha評估纖維蛋白塊形成及相互聯(lián)結（凝塊加固）的速度，反應纖維蛋白原功能。血塊強度血塊強度MA即最大幅度，直接反映纖維蛋白與血小板通過Ga+/XIIIa相互聯(lián)結的最強的動力學特性，代表纖維蛋白凝塊的最終強度主要反應血小板功能GMA 轉化而來，反應血塊的重力 dynes/cm2.G = 5000*MA/(100-MA)凝血總體凝血總體CI綜合凝血指數, R, K, alpha,

5、 MA結合推算出。CI=0.2454R+0.0184K+0.1655MA-0.0241a-0.0220 ）血塊穩(wěn)定性血塊穩(wěn)定性LY30EPL MA出現后30分鐘內血塊消融的比例%。MA出現后預計的血塊消融的%。US Patent 6,787,363低凝低凝高凝高凝纖溶亢進纖溶亢進a: 1,2,3,5,6,7,8,9,13,14b: 1,2,3,5,6,7,8,9,11,13,14c: 1,11,12,15,18,19,21d: 1,2,3,5,6,7,8,9,11,13,26e: 1,2,3,5,6,7,8,9,11,13,14,26f: 1,2,3,5,6,7,11,13g: 1,2,3,5

6、,6,7,8,9,11,12,13,26,27h: 1,2,3,5,6,11,13i: 1,2,3,4,5,6,7,8,9,14,26j: 1,2,3,4,5,14k: 1,10,11,12,15,19l:10,11,15,16,17,18,19,20,21,22,23,24,25m:10,11,15,16,17,18,19,20,21,22,23,24,28n: 10,11,15,17,18,19,20,o:10,11,16,17,18,19,20,21,22,23,24,25 1.Mallett SV, Cox JA. Thrombelastograph? Analysis. Britis

7、h Journal of Anaesthesia. 1992,69:307-313.2.Kang YG, Gasior TA. Blood Coagulation During Liver, Kidney, Pancreas, and Lung Transplantation. Perioperative Transfusion Medicine. 1998.3.Kang Y. Thrombelastograph? Analysis in Liver Transplantation. Seminars in Thrombosis and Hemostasis. 1995. V21 Supple

8、ment 4.4.Kang YG, Lewis JH, Navalgund A, Russell MW, Bontempo FA, Niren LS, Starzl TE. Epsilon-aminocaproic Acid for Treatment of Fibrinolysis During Liver Transplantation. Anesthesiology. 1987:66(6):766-773.5.Kang YG, Martin DJ, Marquez J, et al. Intraoperative Changes in Blood Coagulation and Thro

9、mbelastograph Monitoring in Liver Transplantation. Anesthesia and Analgesia. 1985. 64(9):888-896.6.Kang YG, Monitoring and Treatment of Coagulation. Hepatic Transplantation. 1986. 151-173.7.Von Kier S, Smith A. Hemostatic product transfusions and adverse outcomes: focus on point-of-care testing to r

10、educe transfusion need. J Cardiothorac Vasc Anesth 2000;14(3 Suppl 1):1521.8.Shore-Lesserson L, Manspeizer HE, Deperio M, et al. Thromboelastography-guided transfusion algorithm reduces transfusions in complex cardiac surgery. Anesth Analg, 1999,88:312-319.9.Spiess BD. Perioperative Coagulation Moni

11、toring. Perioperative Transfusion Medicine. 1998.10. Gibbs NM, Crawford GPM, Michalopoulos N. Thrombelastograph Patterns Following Abdominal Aortic Surgery. Anaesth. Intens Care. 1994:22: 534-538.11. Spiess BD, Ivankovich AD. Thrombelastograph? Analysis: A Coagulation-Monitoring Technique applied to

12、 Cardiopulmonary Bypass. Monograph of the Society of Cardiovascular Anesthesia. Ed. Ellison and Jobes: 1988.12. Sharma, SK. Philip, J; Whitten, CW. MD; Padakandla, UB. MD; Landers, DF. Assessment of Changes in Coagulation in Parturients with Preeclampsia Using Thromboelastography. Clinical Investiga

13、tions Anesthesiology. 90(2):385-390, February 1999.13. Sharma S.K.; Vera R.L.; Stegall W.C.; Whitten C.W. Management of a Postpartum Coagulopathy Using Thrombelastography. Journal of Clinical Anesthesia, Volume 9, Number 3, May 1997, pp. 243-247 14. Whitta RKS, Cox DJA, Mallett SV. Thrombelastograph

14、? Analysis reveals two causes of haemorrhage in HELLP syndrome. British Journal of Anaesthesia. 1995:74:464-46815. Caprini JA, Arcelus JI, Laubach M, et al. Postoperative hypercoagulability and deep-vein thrombosis after laparoscopic cholecystectomy. Surgical Endoscopy. (1995) 9: 304-309.16. R. Rai,

15、 E. Tuddenham, L. Regan. Pre-pregnancy thrombophilic abnormalities are associated with subsequent spontaneous abortion HUM REPROD.1999. 15: 168-16917. Tuman KJ, Spiess B, McCarthy R, Ivankovich AD. Effects of Progressive Blood Loss on Coagulation as Measured by Thrombelastograph? Analysis. Anesth An

16、alog. 1987:66:856-63.18. Caprini JA, Zuckerman L, Cohen E. Vagher JP, Lipp V. The Identification of Accelerated Coagulability. Thrombosis Research. 1976:9:167-180.19. H. W. Grant G. P. HadleyPrediction of neonatal sepsis by thromboelastography. Pediatr Surg Int. 1997:12:289-292.20. Kaufmann CR, Dwye

17、r KM, Crews JD, Dols SJ, Trask AL. Usefulness of Thrombelastograph?Analysis in Assessment of Trauma Patient Coagulation. Journal of Trauma, Injury, Infection, and Critical Care. 1997:V42, No4.21. Vig S, Chitolie A, Bevan DH, Halliday A, Dormandy J. Thromboelastography: A Simple Screen for Hypercoagu

18、lable States, Hyperhomocysteinaemia and a Predictor of Failure Following Peripheral Arterial Intervention. Abstract presented at the Surgical Research Meeting, Royal Free Hospital, London, England, December 2, 1999.22. Ng KF, Lo JW. The development of hypercoagulability state, as measured by thrombe

19、lastography, associated with intraoperative surgical blood loss. Anesth Intensive Care, 1996, 24:20-25.23. Ruttmann TG, James MFM, Viljoen JF. Haemodilution Induces a Hypercoagulable State. British Journal of Anaesthesia. 1996:76:412-414.24. Mardel SN, Saunders FM, Allen H, Menezes G, Edwards CM, Ol

20、lerenshaw L, Baddeley D, et al. Reduced quality of clot formation with gelantin-based plasma substitutes. British Journal of Anaesthesia. 1998;80:204-207.25. Heather BP, Jennings SA, Greenhalgh RM. The saline dilution test - a preoperative predictor of DVT. Br. J. Surg. 1980;V67:63-65.26. D. Royston

21、 and S. von Kier. Reduced haemostatic factor transfusion using heparinase-modified thrombelastography during cardiopulmonary bypass. Br J Anaesth 86:575-578, 2001.27. Mongan P, Hosking M. The Role of Desmopressin Acetate in Patients Undergoing Coronary Artery Bypass Surgery. Anesthesiology. 1992:77:

22、38-46.28. Ng KFJ, Lam CCK, Chan LC. In vivo effect of haemodilution with saline on coagulation: a randomized trial. Br J Anaesth 2002; 88: 47580.29. Colman RW et al. Haemostasis and Thrombosis, Basic Principles and Clinical . Neoplasia 2001; 3: 371384. Colman RW et al (eds) Haemostasis and Thrombosi

23、s, Basic Principles and Clinical . Neoplasia 2001; 3: 371384.30. Lbid, pp. 1534-153831. Lbid, pp. 795-80432. Hensley FA, Martin DE. A. practical approach to cardiac anesthesia, 2. nd. ed. Boston: Little,. Brown and Company,2001,451-461.33. Van der Linden, J, et al. Aprotinin decreases postoperative

24、bleeding and number of transfusions in patients on clopidogrel undergoing coronary artery bypass graft surgery. Circulation 2005;112: I276-I280.7000.TEG參數值參數值臨床分析臨床分析建議治療建議治療說明說明R 4 min酶動力型高凝抗凝藥物#低體溫狀態(tài)：如果手術后病人體溫很低，我們建議將病人的一個血樣的測試溫度設置為與病人體溫相同的溫度，另一個血樣的測試溫度設置為37。那么病人凝血狀況的差異可能是由于體溫過低造成的。如果低體溫病人正在出血，但他的

25、凝血狀態(tài)在37是正常的，則意味著當他的體溫回升后，出血就會停止。另一方面，如果血樣在37顯示凝血異常的，而病人在出血，那么我們應該對病人的凝血異常進行治療，直到其血樣在37測量是正常的，因此此時如果低體溫病人仍然持續(xù)出血，原因可能就是體溫過低造成的。#DDAVP：MA值介于4654之間時反映有輕微的血小板功能不良，可通過加入高VWF因子、因子水平的血漿，或者通過其他未確定的機理，采用DDAVP來提高血小板效力，或加入1u血小板。反之，也可以考慮延遲或忽略治療，等待病人自己的血小板功能恢復。如果TEG測試得出了正常的彈力圖，而病人仍在出血：考慮考慮VWF因子疾病因子疾?。篤WF因子缺乏。血凝塊功

26、能是好的，但由于血小板-內皮間的粘附性差，造成血凝塊不能粘附到受損的血管位置。建議采用DDAVP（釋放VWF因子）或FFP/冷沉淀（含有VWF因子）?？紤]抗血小板藥物作用考慮抗血小板藥物作用：采用血小板圖檢測抗血小板治療的影響。考慮機械性出血考慮機械性出血：如果排除了VWF因子缺乏和抗血小板藥物的影響，最后應該考慮是由于手術原因造成出血。復溫和MA的關系：在復溫過程中血樣的MA值比魚精蛋白中和后血樣的MA值低57mm左右。因此在手術的復溫階段中建議采用診斷樹。如果病人沒有接受過肝素治療，則以自然血為基礎評估凝血狀態(tài)。因為我們推薦在模擬條件下運行病人的血樣，因此，在病人血液中不存在肝素時，建議不

27、需用肝素酶杯進行檢測。11min R 14 min凝血因子x 4 FFP or 16 ml/kg1、5、2646mm MA 54 mm血小板功能0.3mcg/kg DDAVP27、11#41mm MA 73血小板型高凝抗血小板治療R73酶動力型和血小板型高凝抗血小板治療和抗凝藥物1、11、10、28 45纖維蛋白原水平0.06 u/kg 冷沉淀5LY307.5%, C.I.3.0原發(fā)性纖溶亢進抗纖溶藥物5、1LY307.5%, C.I.3.0繼發(fā)性纖溶亢進抗凝藥物5、1、15出血血栓急性出血風險急性出血風險血制品管理血制品管理再探查再探查未成熟的血塊消融未成熟的血塊消融凝血酶產生降低凝血酶產生

28、降低弱的血凝塊弱的血凝塊動力動力/外科原因外科原因血小板粘附降低血小板粘附降低血小板抑制藥血小板抑制藥低凝血因子造成低凝低凝血因子造成低凝低血小板數量低血小板數量/功能造成低凝功能造成低凝低纖維蛋白原造成低凝綠色 = kaolin 和肝素酶 (KH)黑色 = 只有kaolin (K)R 值 KH = K 提示沒有肝素存在R 值 KH K 提示有肝素存在除了抗FXa活性測試以外.,TEG普通測試的敏感性比其他傳統(tǒng)凝血測試對低濃度UFH, LMWH, DPD高.TEG肝素酶測試能檢測出極低濃度(0.005 U/ml)的UFH,LMWH,DPD.對于低濃度(0.005-0.05 U/ml)的UFH

29、,TEG肝素酶測試的敏感性比抗FXa活性測試高.TEG檢測與傳統(tǒng)凝血檢測(PT,aPTT,TT,抗FXa活性測試)對UFH, LMWH, DPD監(jiān)測結果的比較 Blood Coagul Fibrinolysis. 2006 Mar;17(2):97-104. Coppell JA, Thalheimer U, Zambruni A, aHaemophilia Centre and Haemostasis Unit bLiver Transplantation and Hepatobiliary Medicine, Royal Free Hospital, UK.對于殘留肝素的抗凝效果，對于殘留

30、肝素的抗凝效果，ACTACT比比aPTT, TEGaPTT, TEG和全血肝素測試的敏感性更低。和全血肝素測試的敏感性更低。Heparin detection by the activated coagulation time: a comparison of the sensitivity of coagulation tests and heparin assays.ACT檢測肝素:凝血測試與肝素測試敏感性的比較 Cardiothorac Vasc Anesth. 1997 Feb;11(1):24-8. Murray DJ, Brosnahan WJ, Department of Ane

31、sthesia, Washington University School of Medicine, St. Louis, MO 63110, USA. TEG TEG 能及時準確地反映血凝塊的形成、溶解的全過程，對術中的異常出血能在短能及時準確地反映血凝塊的形成、溶解的全過程，對術中的異常出血能在短時間內作定性診斷，尤其是在魚精蛋白綜合肝素不全時，時間內作定性診斷，尤其是在魚精蛋白綜合肝素不全時，TEG TEG 的的R R 值明顯增加，值明顯增加，其敏感性與特異性明顯優(yōu)于其敏感性與特異性明顯優(yōu)于ACTACT。血栓彈性描記儀的臨床應用初探劉克玄 黃文起 等. 中山醫(yī)科大學附屬第一醫(yī)院麻醉科 現

32、代醫(yī)學儀器與應用2000年 12卷 3期 雖然術后雖然術后ACTACT恢復到術前水平恢復到術前水平, ,但魚精蛋白難以中和敏感性小分子量肝素但魚精蛋白難以中和敏感性小分子量肝素, ,殘余肝素殘余肝素仍影響術后凝血功能仍影響術后凝血功能, ,不能僅憑不能僅憑ACTACT判斷魚精蛋白中和肝素的滿意程度判斷魚精蛋白中和肝素的滿意程度, ,提示我們提示我們, ,體體外循環(huán)中應選用大分子量肝素抗凝。用肝素酶中和肝素的外循環(huán)中應選用大分子量肝素抗凝。用肝素酶中和肝素的TEGTEG可反映實際凝血功能可反映實際凝血功能, ,迅速排除肝素影響迅速排除肝素影響, ,也可在體外循環(huán)中進行監(jiān)測也可在體外循環(huán)中進行監(jiān)測

33、, ,及早提供凝血異常的資料及早提供凝血異常的資料, ,指導術指導術后治療。后治療。用血栓彈力圖評價體外循環(huán)中凝血功能的改變王仕剛、倪虹 、龔慶成。阜外心血管病醫(yī)院體外循環(huán)科中華胸心血管外科雜志2003年10月第19卷第5期 Royston D and von Kier S. Br J Anaesth. 2001; 86:575. 組組對照組對照組(n=30)TEG-檢測檢測(n=30)輸血病人105*FFP 冰凍新鮮血漿(units)165*血小板 (units)91*12 hr胸腔引流 (ml)390470Prospective, randomly controlled studyCard

34、iac surgical patientsp 0.05CTD = chest tube drainageFFP = fresh frozen plasmaShore-Lesserson L, et al. Anesth Analg. 1999; 88:312-9 隨機對照 心外病人 只針對手術病人p 0.05CTD = chest tube drainageFFP = fresh frozen plasmaRBC = red blood cells# 輸血病人輸血病人對照對照(n=53)# 輸血輸血TEG-檢測檢測(n=52)RBC紅細胞紅細胞術中1723術后1610總計3122FFP 冰凍新

35、鮮血漿冰凍新鮮血漿術中83術后112*總計164*Platelets 血小板血小板術中85術后93總計157*24 hr 胸腔引流胸腔引流(ml)901702外科原因外科原因? (90% 可能可能)血管內皮相關的問題血管內皮相關的問題?血小板抑制藥的使用血小板抑制藥的使用?再手術的類型監(jiān)測內容常規(guī)檢查 (單位)TEG (單位)Total28/4885.7%9/5911.5%*CABG16/3554.5%6/4431.4%*開心手術12/1339.0%03/1482.0%*Spiess BD, et al. J Cardiothorac Vasc Anesth. 1995; 9:168.出血血栓

36、急性血栓風險急性血栓風險血栓形成的風險分層血栓形成的風險分層檢測藥物療效檢測藥物療效低纖維溶解活性低纖維溶解活性過多的凝血酶產生過多的凝血酶產生血小板活性亢進血小板活性亢進血小板型高凝血小板型高凝酶動力型高凝酶動力型高凝酶動力和血小板型高凝酶動力和血小板型高凝高 MA 是評估缺血事件最敏感的參數80% 敏感性非心外手術病人 (n=240)McCrath et al. Analg Anesth 2005; 100:1576PCI (n=192)Gurbel et al. JACC 2005; 46:1820出血血栓“急性急性” 凝血風險凝血風險原發(fā)纖溶和繼發(fā)纖溶的區(qū)別原發(fā)纖溶和繼發(fā)纖溶的區(qū)別過多

37、的纖溶酶過多的纖溶酶過多的纖維蛋白形成過多的纖維蛋白形成 TAFI 活性不足活性不足TAFITAFI：凝血酶激活的纖溶抑制物：凝血酶激活的纖溶抑制物 原發(fā)性纖溶亢進原發(fā)性纖溶亢進繼發(fā)性纖溶亢進繼發(fā)性纖溶亢進 1. Tanaka KA, Sato N, Kelly AB, Szlam F, Levy JH. Monitoring Platelet Function during Cardiopulmonary Bypass in the Presence of Tirofiban. Anesth Analg. 2003; 96, SCA 53.2. Waters JH, Anthony DG,

38、Gottlieb A, Sprung J. Bleeding in a Patient Receiving Platelet Aggregation Inhibitors. Anesth Analg. 2001;93:878-882.3. Stogermuller B, Stark J, Willschke H, Felfernig M, Hoerauf K, Kozek-Langenecker SA. The Effect of Hydroxethyl Starch 200kD on Platelet Function. Anesth Analg. 2000;91:823-827.4. Ni

39、elsen VG, Geary BT, Baird MS. Evaluation of the Contribution of Platelets to Clot Strength by Thrombelastograph?Analysis in Rabbits: The Role of Tissue Factor and Cytochalasin D. Anesth Analg. 2000;91:35-39. 5. Mousa S, Khurana S, Forsythe MS. Comparative In Vitro Efficacy of Different Platelet Glyc

40、oprotein IIb/IIIa Antagonists on Platelet-Mediated Clot Strength Induced by Tissue Factor with Use of Thrombelastograph?Analysis. Arterioscler Thromb Vasc Biol. 2000; V20: 1162-1167. 6. McCarthy RJ, Tuman KJ, Chen B, Ivankovich AD. Platelet Integrin Inhibition with c7E3 Enhances the Correlation betw

41、een Platelet Aggregometry and Thrombelastograph(TEG) MA Values. Anesth Analg. 1998;86;S219.7. Greilich PE, Carr ME, Cooley MV, et al. Dose Dependent Effects of c7E3 Fab on Modified Thrombelastograph?Analysis in Healthy Volunteers. Anesth Analg. 1998;86;S64.8. McNulty SE, Sasso P, Vesci J, Schieren H

42、. Platelet Concentrate Effects on Thrombelastograph?Analysis. Journal of Cardiothoracic and Vascular Anesthesia. December 1997:V11, No. 7, pp 828-830.9.Heerden PVV, Gibbs NM, Michalopoulos N. Effect of Low Concentrations of Prostacyclin on Platelet Function in vitro. Anesthesia Intensive Care. 1997;

43、 25: 343-346.10. Khurana S, Mattson JC, Westley S, ONeill WW, Timmis GC, Safian RD. Monitoring platelet glycoprotein IIb/IIIa-fibrin interaction with tissue factor-activated Thrombelastograph?analysis. J Lab Clin Med 1997:V130, No. 4, 401-411.11. Greilich PE, Alving BM, ONeill KL, Chang AS, Reid TJ.

44、 “A Modified Thrombelastograph Method for Monitoring c7E3 Fab in Heparinized Patients. Anesth Analg. 1997;84:31-8.12. Klindworth JT, MacVeigh I, Ereth MH. The Platelet Activated Clotting Test (PACT) Predicts Platelet Dysfunction Associated With Cardiopulmonary Bypass (CPB). Anesth Analg. 1996;82;SCA

45、99.13. Patel R, Tuman KJ, Patel RB, McCarthy RJ, Ivankovich AD. Comparison of Thrombelastograph?Analysis and Platelet Aggregometry. Anesthesiology. Sept. 1991:V72, No 3A. 14. Royston D. Aprotinin Prevents Bleeding and Has Effects on Platelets and Fibrinolysis. Journal of Cardiothoracic and Vascular

46、Anesthesia. 1991:5(6):18-23. 15. Gaetano G, Bottecchia D, Vermylen J. Effect of Platelets on Clot Structuration. A Thrombelastograph Study. Thrombosis Research. 1973:V3, 425-435. XIIIXIIIa可溶性纖維單體血小板聚集(GPIIb/IIIa + 纖維蛋白原)強的血小板-纖維蛋白網纖維蛋白網弱的血小板血塊弱纖維蛋白血塊血小板聚集+纖維蛋白網血塊發(fā)展血小板被激活纖維蛋白原靜止的血小板凝血酶 凝血因子/旁路血小板聚集+纖

47、維蛋白網弱纖維蛋白血塊XIIIXIIIa強的血小板-纖維蛋白血塊凝血因子/旁路纖維蛋白原靜止的血小板Kaolin 激活的血液樣本MAtotal(MAKH)纖維蛋白網弱纖維蛋白血塊可溶性纖維單體弱的血小板血塊血小板聚集(GPIIb/IIIa + 纖維蛋白原)血塊發(fā)展凝血酶 血小板被激活凝血酶XIIIXIIIa纖維蛋白網弱的纖維蛋白血塊纖維蛋白原靜止的血小板肝素化的血樣MAfibrin激活劑 FXXXX凝血因子/旁路可溶性纖維單體纖維蛋白網血塊發(fā)展XIIIXIIIa血小板-纖維蛋白血塊肝素化的血樣MAPiActivator FX XX XX XX XX XX XX XX XX XX XX XX X

48、ADP or AAXXXX凝血因子/旁路纖維蛋白原靜止的血小板凝血酶可溶性纖維單體纖維蛋白網血小板聚集+纖維蛋白網血塊發(fā)展血小板聚集(GPIIb/IIIa + 纖維蛋白原) A 激活劑FADP ADP 激活劑AA AA 激活劑CK AADPAA抽血針管MATHROMBINMAFIBRINMAADPMAAA肝素化血樣KaolinCaCl2枸櫞酸化血樣P1ADPAAKHMA = 69.1 mm:纖維蛋白原 + 凝血酶激活的血小板功能MA = 10.0 mm: 纖維蛋白原 (沒有血小板功能)MA = 69.3 mm: 纖維蛋白原 + ADP 激活的血小板功能MA = 54.6 mm: 纖維蛋白原 +

49、 AA 激活的血小板功能ADP: 0% 抑制率/100% 聚集率AA: 24.5%抑制率/75.5% 聚集率含有ADP和AA的全套試劑包，或者ADP或AA獨立檢測的試劑包。KHADPAAFibrinogen出血風險出血風險: 可能較低可能較低ADPAAFibrinogenKH出血風險出血風險: 可能較高可能較高Inhibition 50% Inhibition = 8.4% Aggregation = 91.6MATHROMBINMAAAMAFIBRIN%Inhibition = 0.0%Aggregation = 100加用雙倍劑量 FADPAAADP inhibition: 99.5% A

50、A inhibition: 0.5%KHMA(mm) 75.8 18.3 18.6 75.5FADPAAADP inhibition: 91.1%AA inhibition: 67.6%KHMA(mm): 73.6 18.3 23.2 36.2 PlateletMapping: 監(jiān)測/調節(jié)抗血小板治療 1. Copeland JG, Arabia FA, Tsau PH, Nolan PE, McClellan D, Smith RG, Slepian MJ. Total artificial hearts Bridge to transplantation. Cardiol Clin 200

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53、grel and the effect of non-responders among patients with stable angina pectoris scheduled for elective coronary stent placement. Thromb Haemos 2000; 89: 783-7.5. Gurbel PA, Cummings CC, Bell CR, Alford AB, Meister AF, Serebruany VL. Onset and extent of platelet inhibition by clopidogrel loading in

54、patients undergoing elective coronary stenting: the Plavix reduction of new thrombus occurrence (PRONTO) trial. Am Heart J 2003; 145:239-247.6. Jremo P, Lindahl TL, Fransson SG, Richter A. Individual variations of platelet inhibition after loading doses of clopidogrel. J Intern Med 2002; 252:233-238

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