Predictors and Impact of Bleeding Complications in Percutaneous Coronary Intervention, Acute Coronary Syndromes, and ST-Segment Elevation Myocardial Infarction
Predictors and Impact of Bleeding Complications in Percutaneous Coronary Intervention, Acute Coronary Syndromes, and ST-Segment Elevation Myocardial Infarction
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DOI：
10.1016/j.amjcard.2009.06.020
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发表时间：
2009-09-07
影响因子：
2.8
通讯作者：
Manoukian, Steven V.
中科院分区：
文献类型：
--
作者：
Manoukian, Steven V.
尽管在经皮冠状动脉介入治疗（PCI）、急性冠状动脉综合征（ACS）和ST段抬高型心肌梗死（STEMI）的急性和慢性环境中使用口服和静脉内抗血小板和抗凝血酶治疗可有效降低缺血性事件发生率，但它们在机制上与出血风险增加有着千丝万缕的联系。随着疗程的延长，使用更复杂、更有效的治疗方案，增加的疗效可能会被住院和门诊患者的大出血、小出血和滋扰性出血的增加所抵消。因此，预期停止抗血栓治疗和依从性的挑战更频繁。大量数据表明，出血并发症（1）发生频率相对较高;（2）独立影响不良结局，如死亡率;（3）在不良影响死亡率方面与缺血性事件具有相似的重要性;（4）可通过识别出血的患者、临床表现、治疗和手术风险因素进行预测;（5）可通过药理学和非药理学方法进行调整。与出血风险增加相关的因素包括：（1）患者特征（包括高龄、女性、高血压、肾脏疾病、贫血、既往出血史，可能还有糖尿病），（2）临床表现（PCI的出血率最低，ACS较高，STEMI最高），（3）心脏生物标志物和/或心电图异常，（4）侵入性操作（如心导管插入术和PCI）;（5）抗血小板和抗凝血酶治疗的选择。在出血评估的背景下，循证决策应始终导致选择适当的药理学和非药理学策略、侵入性或保守性管理计划以及支架类型（裸金属与药物洗脱），这些将提供最佳的获益和风险平衡，以优化结局。(C)2009 Elsevier Inc. All rights reserved. (Am J Cardiol 2009;104[增刊]：9 C-15 C）
Although the use of oral and intravenous antiplatelet and antithrombin therapy in the acute and chronic settings of percutaneous coronary intervention (PCI), acute coronary syndromes (ACS), and ST-segment elevation myocardial infarction (STEMI) effectively reduce ischemic event rates, they are mechanistically and inextricably linked to an increased risk of bleeding. As longer courses, of more complex, potent regimens are used, increased efficacy may be offset by increases in major, minor, and nuisance bleeding, both in the inpatient and outpatient setting. Consequently, more frequent challenges with cessation of and compliance with antithrombotic therapy are to be expected. Extensive data indicate that bleeding complications (1) occur with relative frequency; (2) independently affect adverse outcomes, such as mortality; (3) carry similar importance in adversely influencing mortality as ischemic events; (4) can be predicted by recognizing patient, presentation, treatment, and procedural risk factors for bleeding; and (5) can be modified by pharmacologic and nonpharmacologic means. Factors associated with increased bleeding risk include: (1) patient characteristics (including advanced age, female sex, hypertension, renal disease, anemia, previous history of bleeding, and perhaps diabetes mellitus), (2) clinical presentation (bleeding rates appears lowest for PCI, higher for ACS, and highest for STEMI), (3) abnormalities of cardiac biomarkers and/or electrocardiography, (4) invasive procedures (such as cardiac catheterization and PCI), and (5) the choice of antiplatelet and antithrombin therapy. In the context of a bleeding assessment, evidence-based decision making should always result in the selection of appropriate pharmacologic and nonpharmacologic strategies, invasive or conservative management plans, and stent types (bare metal vs drug-eluting) that will offer the best balance of benefit and risk with the goal of optimizing outcomes. (C) 2009 Elsevier Inc. All rights reserved. (Am J Cardiol 2009;104[suppl]:9C-15C)