高龄老年人冠心病合并肺栓塞一例.ppt

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1、高龄老年人冠心病合并肺栓塞一例,北京大学第一医院田清平2013-9-28,何，女，85岁主因间断胸痛10余年，加重4天急诊入院10余年来间断胸痛，多于情绪激动或劳累时发生，为心前区闷痛，无放射、不伴心悸、恶心、黑曚等，含服硝酸甘油约半小时缓解；曾行ECG示“T波改变”；不规律服用硝酸酯类药物及血脂康等；约3-4月发作一次4天前散步时上述症状再次发作，性质同前，含服硝酸甘油10min缓解。1天前再次发作，含服硝酸甘油及速效救心丸无明显缓解,高血压病40余年，血压最高200/110mmHg，服用拜新同，血压控制在140/90mmHg左右20余年前诊为“TIA、脑梗塞”20年前曾患“胃溃疡”，近期胃

2、镜提示“糜烂性胃炎”，间断服用PPI类药物19年前诊为“肺栓塞”，原因考虑为下肢深静脉血栓脱落所致，此后长期服用华法林无烟酒等不良嗜好其妹患高血压病，一子死于脑血管病,入院查体,血压165/50mmHg，脉搏53次/分双肺呼吸音粗，未闻及干湿性罗音心界不大，心率53次/分，律齐，各瓣膜区未闻及杂音及附加心音，未闻及心包摩擦音腹软，肝脾肋下未及双下肢不肿,血WBC、PLT正常，Hb115g/L；尿便常规正常肝肾功能正常TG1.25mmol/L,TCHO3.66mmol/L,HDL1.04mmol/L,LDL2.14mmol/LCK、CK-MB正常，CTNI0.53ng/ml PT33.22s，I

3、NR3.07，D-Dimer正常,非ST段抬高急性冠脉综合症高血压病3级 极高危肺栓塞陈旧性脑梗塞胃溃疡,初步诊断？,药物：硝酸酯类药物（静脉口服）他汀（普伐他汀）ACEI/ARB（替米沙坦）钙拮抗剂（氨氯地平）阻滞剂 抗栓治疗？,治疗,阿司匹林+氯吡格雷单用华法林阿司匹林或氯吡格雷+华法林阿司匹林+氯吡格雷+华法林其他选择？,血栓栓塞,出血,血栓栓塞,1次VTE抗磷脂综合症遗传学血栓形成倾向男性近端静脉残余血栓形成出院时超声提示右心功能不全,出血,老年，尤其75岁消化道出血病史非心源性血栓所致卒中病史、CKD、肝病合并抗血小板治疗（应尽量避免）其他严重的急慢性疾病抗凝药控制不良抗凝治疗未达标

4、,停用华法林阿司匹林100mg+氯吡格雷75mg,下一步？,择期CAG,LM（-）LAD近中段中重度钙化，中段弥漫长病变，狭窄70-80%，D1开口狭窄70%LCX斑块浸润，OM1发出后狭窄40-50%，OM近端狭窄40-50%RCA（-）,药物治疗,阿司匹林100mg40mgQd氯吡格雷75mg普伐他汀10mgQn（LDL2.14mmol/L)替米沙坦80mgQd氨氯地平5mgQd埃索美拉唑20mgQd,2月后,出院2月来规律服药，胸闷等症状发作明显减少1天前无诱因发作三次，心前区紧缩感，伴憋气，无胸痛，前2次含服硝酸甘油约10min缓解，第3次20min不缓解查体：BP125/60mmHg

5、，HR50次/分，心肺腹未见明显异常，双下肢轻度可凹性浮肿ECG较前无明显演变CK、CK-MB正常，CTNI0.23ng/ml D-Dimer3.03mg/LPH7.433，PO282.1mmHg，PCO237.2mmHg，SO296.4%,ACS?,下肢血管彩超：双下肢动脉粥样硬化，右侧小腿肌间静脉血栓形成，范围1.5 0.7cm，深静脉未见明显血栓CTPA：双肺动脉主干及分支未见明显异常,下一步治疗措施？,VTE?,阿司匹林加量至100mg+氯吡格雷dual antiplatelet therapy(DAPT)阿司匹林或氯吡格雷+华法林oral anticoagulation(OAC)阿司

6、匹林+氯吡格雷+华法林triple oral antithrombotic therapy(TOAT)其他,TOAT vs.DAPT,临床证据较少，多来自观察性研究TOAT似乎优于DAPT,In a study of 426 patients with atrial fibrillation(AF)undergoing percutaneous coronary intervention(PCI),DAPT was prescribed in 41 and TOAT in 50 percent.Non-anticoagulation was associated with increased

7、mortality(28 versus 18 percent;hazard ratio HR 3.43,95%CI 1.61-7.54).In a propensity matching study of 604 registry patients with AF undergoing PCI,OAC prescription at discharge was associated with a lower rate of major adverse cardiovascular events(HR 0.40,95%CI 0.22-0.74)and all-cause mortality(0.

8、34,95%CI 0.17-0.69).In a retrospective study 239 patients on OAC(AF was the indication for OAC in the majority)who underwent PCI,patients who were on DAPT,compared to patients on TOAT,had a significantly higher rate of stroke(8.8 versus 2.8 percent)and ST(5.9 versus 1.9 percent),respectively,at 12 m

9、onths.As expected,patients treated with aspirin and warfarin had a higher incidence of ST compared to those on TOAT(15.2 versus 1.9 percent).Two studies have shown no significant difference in major adverse cardiovascular outcomes.In the first,of the 515 patients on OAC who underwent PCI with drug-e

10、luting stents(DES),60 percent were discharged on TOAT and 40 percent on DAPT.There was no significant difference in the development of major adverse cardiovascular events of the two groups,respectively,during the required period of DAPT(4.2 and 7.2 percent;odds ratio OR 0.61,95%CI 0.29-01.28)or at t

11、wo years(14.1 and 18.0 percent;OR 0.76,95%CI 0.48-01.21).In the second study,there was no significant difference in the rates of major adverse cardiovascular events in 132 AF patients on OAC at low thromboembolic risk(CHADS2 score 2)who underwent PCI,TOAT vs.OAC+氯吡格雷/阿司匹林,WOEST研究（TOAT vs.OAC+氯吡格雷）：T

12、OAT出血风险更高；OAC+氯吡格雷在全因死亡和心梗、卒中、血运重建等复合终点方面优于TOAT组 局限性病例数较少（573例）；支架内血栓形成的比较其他研究：回顾性研究（405例）：OAC+氯吡格雷/阿司匹林比TOAT心血管事件明显239例：OAC+阿司匹林组心梗等事件，DAPT组卒中,基于目前的证据，对于PCI术后同时具有DAPT和OAC应用指征的患者，推荐TOAT，如果出血风险高，基于WOEST试验结果，推荐OAC+氯吡格雷对于未行PCI，但具有DAPT和OAC应用指征的患者，临床试验数据非常有限，一般推荐OAC+一种抗血小板药物，对于出血风险低的患者TOAT也可选择,低分子肝素与华法林重叠，过渡为单用华法林，调整剂量使INR2-3停用阿司匹林氯吡格雷继续使用（PPI）继续冠心病二级预防其他药物：他汀、ARB等,小结,老年患者ACS症状多不典型；高龄老年冠心病患者药物治疗是基石；是否介入治疗需要个体化；抗栓治疗方案需要个体化，需权衡血栓栓塞和出血风险。,专家点评,