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【正文】 Tirofiban + Heparin Reduction in TnI Levels by Tirofiban in UA/NSTEMI: PRISMPLUS TnI=troponin I. Januzzi JL, et al. Am J Cardiol. 2022。290:15931599. Primary Endpoint: Death, MI within 30 Days Absolute Reduction in 30day Death or MI with Eptifibatide vs Placebo (%) (n=2522) (n=2041) (n=3803) (n=1105) % ? ? 0% % ? Time from Onset of Symptoms Bhatt D, Topol E. JAMA. 2022。135:S77S89. Internal Data, Centrocor. Patients (%) EPIC 3 2 1 0 CAPTURE EPILOG EPISTENT Incidence of Severe Thrombocytopenia (Platelet Count 50,000/mm3) Placebo Abciximab Tirofiban TARGET Topol EJ, et al. N Engl J Med. 2022。330:956961. EPILOG. N Engl J Med. 1997。100:20452048. Reversible GP IIb/IIIa in ACS: Death and MI Prior to Catheterization 6% 4% 2% 0% Death/MI Impact of Early PCI on 30day Death/MI PRISMPLUS PURSUIT % % % % 0% 5% 10% 15% 20% PCI 72 hr (n=1228) No early PCI (n=8233) Heparin 31%↓ 6%? % % % % 0% 5% 10% 15% PCI 72 hr (n=287) No early PCI (n=1283) Heparin Tirofiban + Heparin 42%? 23%? Boersma E, et al. Circulation. 1999。 101: 199–209. 阿司匹林 ASA聯(lián)合氯吡格雷對(duì)血栓形成的協(xié)同作用 1 1. Herbert JM et al. Thromb Haemost 1998。 副作用：腹瀉、消化不良、皮膚過敏 粒細(xì)胞減少，血小板減少癥 應(yīng)監(jiān)測(cè)血常規(guī)，短時(shí)應(yīng)用可減少副作用。 GP IIb/IIIa – GP IIb/IIIa UFH 50 U/kg ACT 200 – 250 s UFH 60 U/kg ACT 250 – 300 s Enoxaparin mg/kg IV dalteparin 60IU/kg IV Enoxaparin mg/kg IV dalteparin 60IU/kg IV No additional UFH or LMWH Kereiakes DJ, et al. Am Heart J. 2022。 蛋白 C/蛋白 S 凝血與抗凝系統(tǒng) 內(nèi)源性凝血系統(tǒng) 外源性凝血系統(tǒng) Va 纖維蛋白 VIIIa XIIa XIa IXa VIIaIII Xa IIa 纖維蛋白原 組織因子 途徑抑制物 抗凝血酶 啟動(dòng)階段 少量凝血酶 IX II IXa IIa VII IX VIIa TF V Va X Xa 損傷部位 Monroe DM et al. Arterioscler Thromb Biol 2022。 ?副作用：胃腸道反應(yīng)，胃腸道出血，支氣管痙攣，及皮膚過敏。 60: 347–77. 事件率 (心肌梗死、缺血性腦卒中或者血管性死亡 ) (n = 8,854) (n = 4,496) % % % % % % 0 5% 10% 15% 20% 25% 30% 所有 CAPRIE病人 ?1 (n = 19,185) 先前任何缺血 事件病史 ?2 先前嚴(yán)重急性事件病史 (心肌梗死或腦卒中 )?2 事件率 (%) 阿司匹林 氯吡格雷 11* 28* 34* * 每 1000個(gè)病人每年比阿司匹林多預(yù)防的事件數(shù) ? 隨訪 3年累積發(fā)生事件病人的比例 ? 3年事件率 1. CAPRIE Steering Committee. Lancet 1996。86:713717. Heparin (n=52) Tirofiban + Heparin (n=53) TnI (ng/mL) Baseline Levels Peak Levels P=NS P= 0 6 12 18 PRISMPLUS: Thrombus Grade 0 10 20 30 40 50 Heparin (n=622) Large Tirofiban + Heparin (n=608) Possible Small Moderate Possible Small Moderate Overall Odds Ratio: P= % % Large Recent Occlusion Recent Occlusion Zhao XQ, et al. Circulation. 1999。284:15491558. 6 hours 6–12 hours 12–24 hours 24 hours ? % ? % ? % GP IIb/IIIa Inhibitors: Reduction in Death/MI Associated with Time of Administration from Symptom Onset 4F Coronary Angioscope Intracoronary Ultrasound Common in Patients with Diabetes Schoenhagen P
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