Цитата:
Сообщение от Nastydoc
Уважаемые коллеги,! не нашла в отечественных рекомендациях или плохо смотрела - если больной на варфарине с достигнутым МНО предположим 2.5 поступает с ОКС, ИМ
1. нагрузочную дозу клопидогреля давать (подозреваю что да)
2. тромболизис - относительно противопоказан. стали бы вы проводить?
3. вводить ли болюс гепарина?
4. проводить ли инфузию гепарина в дозах, рекомендованных при окс?
5. низкомолекулярные гепарины стали бы применять?
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К счастью пациентов со STEMI на адекватной антикоагуляции не много. Что вполне закономерно.
"in patients with acute STEMI, when INR is frequently not known: in this situation, regardless of INR values, UFH should be added in moderate doses (e.g. 30–50 U/kg)."
1."Aspirin reduces periprocedural ischaemic complications and should be administered in all patients prior to any PCI procedures. Based on randomised trials and posthoc analyses, pretreatment with clopidogrel is also recommended whenever it can be accomplished. Even if there are no randomised trials on the efficacy and safety of this antiplatelet policy in patients on OAC, analyses from retrospective studies also support this recommendation in this patient group"
2. 3. и 4.
"Current guidelines recommend bridging therapy with unfractionated heparin (UFH) or low-molecular-weight heparin (LMWH) to cover the temporary discontinuation of OAC, if the risk of thromboembolism is considered high (8). These recommendations are based on circumstantial evidence and there are no large randomised trials to support the recommendations. Indeed, there are no randomised trials comparing different strategies to manage long-term OAC during PCI. The safety and feasibility of
heparin bridging therapy has been evaluated in patients who receive long-term OAC and require interruption of OAC for elective surgery or an invasive procedure (63–67). Spyropoulos et al. (64)
showed a major bleeding rate of 3.3% with UFH and 5.5% with LMWH in 901 patients with bridging therapy for an elective surgical or invasive procedure. Another recent study (65) reported a 6.7% incidence of major bleeding with LMWH bridging therapy in patients at risk of arterial embolism undergoing elective noncardiac surgery or an invasive procedure, but also lower (2.9%)
rates of major bleeding have been reported. Reports focusing on PCI are limited, but MacDonald et al. (68) reported that 4.2% of 119 patients developed enoxaparin-associated access site complications during LMWH bridging therapy after cardiac catheterisation.
Thus, there is some suggestion that UFH is better than LMWH for bridging to manage OAC for PCI."
5. "Periprocedural anticoagulation has traditionally been performed with UFH or more recently with LMWHs or direct thrombin inhibitors."
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Ну, и конечно, предпочтителен лучевой доступ.
Кстати нашел в этом документе положение о применении стентов с ускоренной эндотелизацией.
"In patients with very high bleeding risk, DES should be avoided (100) and balloon angioplasty (without stenting) is an option if an acceptable result can be achieved. In this case OAC might be combined with aspirin or a thienopyridine ADP-receptor antagonist in the usual dose. If, however, a stent is needed, BMS, especially “less thrombogenic stents” (carbon- or titanium-nitric-oxide-coated stents, stents with biodegradable coating, or antibody-coated stents capturing endothelial progenitor cells may perhaps need a shorter duration of combination antiplatelet therapy. In general, DES should be avoided in patients under OAC at present. However new third generation DES seem to have accelerated re-endothelialisation and might therefore become of interest in the near future. Respective registries (e.g. the Italian MATRIX registry) and trials to test their usefulness are currently performed"