磺达肝葵钠解读

中危
~3.0%
>10
3~4
高危
~6.0%
—
≥5
IPC：间断充气加压装置；LDUH：低剂量普通肝素；ES：弹力袜 • Roger评分：依据手术类型、麻醉评分、辅助检查等的风险评估模型 • Caprini评分：依据年龄、病史、合并疾病等的风险评估模型 CHEST 2012; 141(2)(Suppl):e227S–e27
治疗静脉血栓栓塞症（深静脉血栓+肺栓塞） 证据级
别 2C(LMWH 2B)
Thank
you
3.1/3.2/3.3AF合并冠心病的抗凝治疗
AF stable coronary artery disease
Triple therapy AF(2)+intracoronary stent
VKA alone
remarks
AF and mitral stenosis
Unable for OA
推荐应用： 更好的选择：
Dabigatran 150mg bid
Perioperative Management
patients temporary interruption of a VKA before surgery
LMWH is preferable (2B)
LMWH Fondaparinux LDUH VKA Aspirin
(1B）
2.1 急性下肢DVT的抗凝方案的选择
patients with acute DVT of the leg treated with VKA therapy
initial treatment with parenteral anticoagulation （1B）
LMWH （2B）
LMWH Once daily
Fondaparinux (2C) serial imaging of the
Over UFH
Administration
With the same dose （2C）
3.3.1/3.3.2选择抗凝疗法作为长期治疗
DVT of the leg no cancer
外源性通路
启 动 阶 段
内源性通路 Xa因子
磷脂 Va因子–Xa因 子 Ca2+
凝血酶原 凝血酶 血小板聚集
直接Xa因子 抑制剂
凝血酶原复合物
放 大 阶 段
纤维蛋白原
纤维蛋白
凝结
Xa因子
Chest 2012;141;e44S-e88
Risk Factors for VTE in Hospitalized Medical Patients
+ not at high risk for major bleeding
low-dose aspirin
LMWH (2B) LDUH (2B) IPC （2C)
Fondaparinux serial imaging of the
( 2C)
2.1Prevention of VTE in Orthopedic Surgery Patients
AF (0-1)+intracoronary stent AF (≧1)+ACS+ unable intra~ stent AF(0) +ACS+ unable intra~ stent
ACCP 9指南 —— 非骨科手术患者的VTE预防
VTE 风险分 级 极低危 低危 VTE 发生 率 <0.5% ~1.5% Roger 评分* <7 7~10 Caprini 评分* 0 1~2 出血风险 — — 低 高 低 高 预防推荐 不预防 机械预防 机械预防（IPC） LMWH LDUH 机械预防（IPC） 机械预防（IPC） LMWH LDUH 建议联用机械预防 （ES或IPC） 机械预防（IPC） 推荐 级别 1B 2C 2C 2B 2B 2C 2C 1B 1B 2C 2C
In acute PE patients, when use a thrombolytic agentIn acute PE patients, Hip fracture surgery (HFS) when use a thrombolytic agent
minimum 10 to 14 days
VKA>LMWH> dabigatran/rivaroxaban (2C)
DVT of the leg and cancer
LMWH>VKA> dabigatran/rivaroxaban (2B)
5.1 急性肺栓塞的抗凝方案的选择
patients with acute PE
initial treatment with parenteral anticoagulation （1B）
In acute PE patients, when use a thrombolytic agentIn acute PE patients, Total Hip Arthroplasty (THA) when use a thrombolytic agent or Total Knee Arthroplasty (TKA)
DVT 深静脉血栓（Deep Vein Thrombosis DVT )，
DVT是在某一条深静脉中出现了血液凝块，血液的正 常流动受阻。DVT通常出现在下肢，如骨盆、大腿和 小腿，于是把下肢DVT又分为：小腿DVT和髂—股 DVT 静脉血栓栓塞症（VTE）：VTE包括深静脉血栓形成 （DVT）及肺栓塞（PE）
orthopedic surgery and, in some countries, in general surgical or medical patients
A substitute for heparin or LMWH for initial treatment of VTE Licensed in Europe and Canada, but not in the United States, as
3. High risk of thromboembolism
Bridging Anticoagulation
Bridging anticoagulation as the administration of
a short-acting anticoagulant
Subcutaneous (SC) LMWH or IV UFH 10- to 12-day during interruption of VKA therapy
(bare-metal 1 m/drug-eluting 3-6m)
VKA+ single antiplatelet (until 12m) VKA alone (after 12m) Dural antiplatelet (until 12m) AF with stable coronary artery disease (after 12m) VKA +single antiplatelet or Triple (until 12m) VKA alone (after 12m) Dural antiplatelet (until 12m) AF stable coronary artery disease (after 12m)
an alternative to heparin or LMWH for the treatment of ACS
Three of the newer indirect factor Xa inhibitors, idraparinux,
idrabiotaparinux, and SR123781A,are second- and thirdgeneration variants（变异体） of fondaparinux
LMWH （2B）
LMWH Once daily
Biblioteka Baidu
Fondaparinux the serial imaging of（2C） Over UFH
Administration
With the same dose （2C）
总结
预防深静脉血栓：
内科急重症+骨科手术 非骨科手术，若LDUH与LMWH禁忌，可选用
LMWH （1B）
fondaparinux the serial imaging of (1B)
LDUH （1B）
Prevention of VTE in Nonorthopedic Surgical Patients
general and abdominal-pelvic surgery
moderate risk for VTE
In the Padua Prediction Score risk assessment model, high risk of VTE is defined by a cumulative score 4 points. In a prospective observational study of 1,180 medical inpatients, 60.3% of patients were low risk and 39.7% were high risk. Among patients who did not receive prophylaxis, VTE occurred in 11.0% of patients vs 0.3% of low-risk patients (HR, 32.0; 95% CI, 4.1-251.0). Among high-risk patients, the risk of DVT was 6.7%, nonfatal PE 3.9%, and fatal PE 0.4%.
Fondaparinux is given at a fixed dose of 2.5 mg daily
for thromboprophylaxis and for the treatment of ACS For treatment of DVT or pulmonaryembolism 5 mg : weight <50 kg 7.5 mg : weight 50 to 100 kg 10 mg : weighing >100 kg. routine coagulation monitoring is not recommended patients with moderate renal insufficiency (ie, CrCl 30-50 mL/min), the dose of fondaparinux should be reduced by 50% contraindicated in patients with renal insufficiency (CrCl <30 mL/min)
stopping VKAs approximately 5 days before surgery （1C）
serial imaging of th Bridging
Anticoagulation （2C）e
1.mechanical heart valve
2. Atrial fibrillation
Prevention of VTE in Hospitalized Acutely Ill Medical Patients
acutely ill hospitalized medical patients
initial treatment with parenteral anticoagulation （1B）
minimum 10 to 14 days LMWH is preferable (2B)
LMWH fondaparinux apixaban、dabigatran、rivaroxaban low-dose UH、VKA、aspirin
(1B）
2.1Prevention of VTE in Orthopedic Surgery Patients
老年科 2012.12
ACCP9 – About Fondaparinux
A first-generation synthetic analog of the antithrombin-binding
pentasaccharide
The prototype for most of the new indirect factor Xa inhibitors Licensed for prevention of VTE in patients undergoing high-risk
2.1.8—2.1.11 房颤患者抗凝的选择
Oral anticoagulation Aspirin low risk （0） Intermediate Risk(1) high risk(≥2)
Unable for OA Unable for OA
Clopidogrel
Dabigatran
VKA