抗血小板藥物抵抗的現(xiàn)象和應(yīng)對(duì)策略課件

抗血小板藥物抵抗的現(xiàn)象和應(yīng)對(duì)策略寧波市第一醫(yī)院陳曉敏寧波市第一醫(yī)院NINGBOFIRSTHOSPITAL抗血小板藥物抵抗1抗血小板藥物抵抗現(xiàn)象4抗血小板藥物抵抗常見于阿司匹林抵抗(Aspirinresistance,AR)氯吡格雷抵抗(Clopidogrelresistance,CR)4臨床抗血小板藥物抵抗抗血小板藥物不能防止患者發(fā)生血栓并發(fā)癥4實(shí)驗(yàn)室抗血小板藥物抵抗抗血小板藥物對(duì)血小板的一種或多種功能沒(méi)有抑制寧波市第一醫(yī)院NINGBOFIRSTHOSPITAL抗血小板藥物抵抗現(xiàn)象2抗血小板藥物抵抗的實(shí)驗(yàn)室依據(jù)人群對(duì)同等劑量抗血小板藥物治療反應(yīng)性存在差異2Hours24HoursResistances63%Resistance=31%△Aggregation(%5Days30DaysResistance30.20(i00170.du401coal△Aggregation%寧波市第一醫(yī)院NINGBOFIRSTHOSPITALGurbeletal.Circulation.2019:107:2908-13抗血小板藥物抵抗的實(shí)驗(yàn)室依據(jù)3抗血小板藥物抵抗的臨床意義AR病人臨床心血管事件發(fā)生率增高Death.MICVANotAspirinResistant,N=309AspirinResistant,N=17=0.03100201900400500600800Gum.PACC2019DaysafterTreatment寧波市第一醫(yī)院NINGBOFIRSTHOSPITALGumPA,etal.JAmCollCardio/2019;41:961-96抗血小板藥物抵抗的臨床意義4抗血小板藥物抵抗的臨床意義20AR病人臨床心血管事件發(fā)生率增高N=9675.1尿11脫氫TXB2濃度(ng/mmo肌酐)*尿11-脫氫τX(jué)B2為血τX(jué)A2代謝產(chǎn)物,間接反映機(jī)體對(duì)阿司匹林的反應(yīng)性寧波市第一醫(yī)院NINGBOFIRSTHOSPITALCirculation2019;105:1650-1655抗血小板藥物抵抗的臨床意義5抗血小板藥物抵抗的臨床意義CR發(fā)生率及臨床意義—Meta分析425項(xiàng)研究3688例冠脈支架術(shù)后病人CR發(fā)生率21%(95%C:17%~25%)4亞急性血栓OR=7.0395%C1:0.63-79.1)P=0.114臨床缺血事件OR=12.02(95%C1:5.91-24.42)P<0.000014心肌壞死OR=2.20(95%C1:0.93-522)P=0.074所有事件OR=8.00(95%CI:3.36-19.05)P<0.00001000.1寧波市第一醫(yī)院AmHeart」2019:154:221231NINGBOFIRSTHOSPITAL抗血小板藥物抵抗的臨床意義6抗血小板藥物抵抗的可能機(jī)制依從性差/劑量不足血小板更新過(guò)快臨床危險(xiǎn)因素治療反應(yīng)性基因多態(tài)性下降藥物相互作用旁路途徑活化寧波市第一醫(yī)院NINGBOFIRSTHOSPITAL抗血小板藥物抵抗的可能機(jī)制7抗血小板藥物抵抗的可能機(jī)制4臨床危險(xiǎn)因素女性糖尿病炎癥介質(zhì)吸煙細(xì)胞因子代謝綜合征血管反應(yīng)性抗血小板急性冠脈綜合征血小板數(shù)量藥物抵抗既往心血管事件血小板功能肝腎功能異常血液系統(tǒng)疾病寧波市第一醫(yī)院NINGBOFIRSTHOSPITAL抗血小板藥物抵抗的可能機(jī)制8抗血小板藥物抵抗的可能機(jī)制4藥物相互作用布洛芬與阿司匹林100內(nèi)aeetASA+布洛芬存活率下降)ASA與coX1不可逆結(jié)合,阻斷AA生成TXA2;12345679布洛芬與CoX-1可逆結(jié)Follow-up(years)合,減弱ASA的作用寧波市第一醫(yī)院NEM2019;345:1809-17NINGBOFIRSTHOSPITALLancet2019;361:573-4抗血小板藥物抵抗的可能機(jī)制9抗血小板藥物抵抗的可能機(jī)制藥物相互作用他汀與氯吡格雷氯吡格雷活性代謝產(chǎn)物CYP3A4阿托伐他汀辛伐他汀代謝CYP3A4寧波市第一醫(yī)院NINGBOFIRSTHOSPITAL抗血小板藥物抵抗的可能機(jī)制10抗血小板藥物抵抗的現(xiàn)象和應(yīng)對(duì)策略課件11抗血小板藥物抵抗的現(xiàn)象和應(yīng)對(duì)策略課件12抗血小板藥物抵抗的現(xiàn)象和應(yīng)對(duì)策略課件13抗血小板藥物抵抗的現(xiàn)象和應(yīng)對(duì)策略課件14抗血小板藥物抵抗的現(xiàn)象和應(yīng)對(duì)策略課件15抗血小板藥物抵抗的現(xiàn)象和應(yīng)對(duì)策略課件16抗血小板藥物抵抗的現(xiàn)象和應(yīng)對(duì)策略課件17抗血小板藥物抵抗的現(xiàn)象和應(yīng)對(duì)策略課件18抗血小板藥物抵抗的現(xiàn)象和應(yīng)對(duì)策略課件19抗血小板藥物抵抗的現(xiàn)象和應(yīng)對(duì)策略課件20抗血小板藥物抵抗的現(xiàn)象和應(yīng)對(duì)策略課件21抗血小板藥物抵抗的現(xiàn)象和應(yīng)對(duì)策略課件22抗血小板藥物抵抗的現(xiàn)象和應(yīng)對(duì)策略課件23抗血小板藥物抵抗的現(xiàn)象和應(yīng)對(duì)策略課件24抗血小板藥物抵抗的現(xiàn)象和應(yīng)對(duì)策略課件25抗血小板藥物抵抗的現(xiàn)象和應(yīng)對(duì)策略課件26抗血小板藥物抵抗的現(xiàn)象和應(yīng)對(duì)策略課件27抗血小板藥物抵抗的現(xiàn)象和應(yīng)對(duì)策略課件28抗血小板藥物抵抗的現(xiàn)象和應(yīng)對(duì)策略課件29抗血小板藥物抵抗的現(xiàn)象和應(yīng)對(duì)策略課件30抗血小板藥物抵抗的現(xiàn)象和應(yīng)對(duì)策略課件31抗血小板藥物抵抗的現(xiàn)象和應(yīng)對(duì)策略課件32抗血小板藥物抵抗的現(xiàn)象和應(yīng)對(duì)策略課件33抗血小板藥物抵抗的現(xiàn)象和應(yīng)對(duì)策略課件34抗血小板藥物抵抗的現(xiàn)象和應(yīng)對(duì)策略課件35抗血小板藥物抵抗的現(xiàn)象和應(yīng)對(duì)策略課件36抗血小板藥物抵抗的現(xiàn)象和應(yīng)對(duì)策略課件37抗血小板藥物抵抗的現(xiàn)象和應(yīng)對(duì)策略課件38抗血小板藥物抵抗的現(xiàn)象和應(yīng)對(duì)策略寧波市第一醫(yī)院陳曉敏寧波市第一醫(yī)院NINGBOFIRSTHOSPITAL抗血小板藥物抵抗39抗血小板藥物抵抗現(xiàn)象4抗血小板藥物抵抗常見于阿司匹林抵抗(Aspirinresistance,AR)氯吡格雷抵抗(Clopidogrelresistance,CR)4臨床抗血小板藥物抵抗抗血小板藥物不能防止患者發(fā)生血栓并發(fā)癥4實(shí)驗(yàn)室抗血小板藥物抵抗抗血小板藥物對(duì)血小板的一種或多種功能沒(méi)有抑制寧波市第一醫(yī)院NINGBOFIRSTHOSPITAL抗血小板藥物抵抗現(xiàn)象40抗血小板藥物抵抗的實(shí)驗(yàn)室依據(jù)人群對(duì)同等劑量抗血小板藥物治療反應(yīng)性存在差異2Hours24HoursResistances63%Resistance=31%△Aggregation(%5Days30DaysResistance30.20(i00170.du401coal△Aggregation%寧波市第一醫(yī)院NINGBOFIRSTHOSPITALGurbeletal.Circulation.2019:107:2908-13抗血小板藥物抵抗的實(shí)驗(yàn)室依據(jù)41抗血小板藥物抵抗的臨床意義AR病人臨床心血管事件發(fā)生率增高Death.MICVANotAspirinResistant,N=309AspirinResistant,N=17=0.03100201900400500600800Gum.PACC2019DaysafterTreatment寧波市第一醫(yī)院NINGBOFIRSTHOSPITALGumPA,etal.JAmCollCardio/2019;41:961-96抗血小板藥物抵抗的臨床意義42抗血小板藥物抵抗的臨床意義20AR病人臨床心血管事件發(fā)生率增高N=9675.1尿11脫氫TXB2濃度(ng/mmo肌酐)*尿11-脫氫τX(jué)B2為血τX(jué)A2代謝產(chǎn)物,間接反映機(jī)體對(duì)阿司匹林的反應(yīng)性寧波市第一醫(yī)院NINGBOFIRSTHOSPITALCirculation2019;105:1650-1655抗血小板藥物抵抗的臨床意義43抗血小板藥物抵抗的臨床意義CR發(fā)生率及臨床意義—Meta分析425項(xiàng)研究3688例冠脈支架術(shù)后病人CR發(fā)生率21%(95%C:17%~25%)4亞急性血栓OR=7.0395%C1:0.63-79.1)P=0.114臨床缺血事件OR=12.02(95%C1:5.91-24.42)P<0.000014心肌壞死OR=2.20(95%C1:0.93-522)P=0.074所有事件OR=8.00(95%CI:3.36-19.05)P<0.00001000.1寧波市第一醫(yī)院AmHeart」2019:154:221231NINGBOFIRSTHOSPITAL抗血小板藥物抵抗的臨床意義44抗血小板藥物抵抗的可能機(jī)制依從性差/劑量不足血小板更新過(guò)快臨床危險(xiǎn)因素治療反應(yīng)性基因多態(tài)性下降藥物相互作用旁路途徑活化寧波市第一醫(yī)院NINGBOFIRSTHOSPITAL抗血小板藥物抵抗的可能機(jī)制45抗血小板藥物抵抗的可能機(jī)制4臨床危險(xiǎn)因素女性糖尿病炎癥介質(zhì)吸煙細(xì)胞因子代謝綜合征血管反應(yīng)性抗血小板急性冠脈綜合征血小板數(shù)量藥物抵抗既往心血管事件血小板功能肝腎功能異常血液系統(tǒng)疾病寧波市第一醫(yī)院NINGBOFIRSTHOSPITAL抗血小板藥物抵抗的可能機(jī)制46抗血小板藥物抵抗的可能機(jī)制4藥物相互作用布洛芬與阿司匹林100內(nèi)aeetASA+布洛芬存活率下降)ASA與coX1不可逆結(jié)合,阻斷AA生成TXA2;12345679布洛芬與CoX-1可逆結(jié)Follow-up(years)合,減弱ASA的作用寧波市第一醫(yī)院NEM2019;345:1809-17NINGBOFIRSTHOSPITALLancet2019;361:573-4抗血小板藥物抵抗的可能機(jī)制47抗血小板藥物抵抗的可能機(jī)制藥物相互作用他汀與氯吡格雷氯吡格雷活性代謝產(chǎn)物CYP3A4阿托伐他汀辛伐他汀代謝CYP3A4寧波市第一醫(yī)院NINGBOFIRSTHOSPITAL抗血小板藥物抵抗的可能機(jī)制48抗血小板藥物抵抗的現(xiàn)象和應(yīng)對(duì)策略課件49抗血小板藥物抵抗的現(xiàn)象和應(yīng)對(duì)策略課件50抗血小板藥物抵抗的現(xiàn)象和應(yīng)對(duì)策略課件51抗血小板藥物抵抗的現(xiàn)象和應(yīng)對(duì)策略課件52抗血小板藥物抵抗的現(xiàn)象和應(yīng)對(duì)策略課件53抗血小板藥物抵抗的現(xiàn)象和應(yīng)對(duì)策略課件54抗血小板藥物抵抗的現(xiàn)象和應(yīng)對(duì)策略課件55抗血小板藥物抵抗的現(xiàn)象和應(yīng)對(duì)策略課件56抗血小板藥物抵抗的現(xiàn)象和應(yīng)對(duì)策略課件57抗血小板藥物抵抗的現(xiàn)象和應(yīng)對(duì)策略課件58抗血小板藥物抵抗的現(xiàn)象和應(yīng)對(duì)策略課件59抗血小板藥物抵抗的現(xiàn)象和應(yīng)對(duì)策略課件60抗血小板藥物抵抗的現(xiàn)象和應(yīng)對(duì)策略課件61抗血小板藥物抵抗的現(xiàn)象和應(yīng)對(duì)策略課件62抗血小板藥物抵抗的現(xiàn)象和應(yīng)對(duì)策略課件63抗血小板藥物抵抗的現(xiàn)象和應(yīng)對(duì)策略課件64抗血小板藥物抵抗的現(xiàn)象和應(yīng)對(duì)