那些病人能从GPIIbIIIaInhibitors获益.ppt
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1、那些病人能从GP IIb/IIIa Inhibitors获益,中国医学科学院 北京协和医学院 心血管病研究所 阜外心血管病医院 袁晋青,主要内容,Characteristics of GP IIb/IIIa Inhibitors GP IIb/IIIa Inhibitors in ACS GP IIb/IIIa Inhibitors in STEMI GPIIb/IIIa Inhibitors and PCI,一、Characteristics of GP IIb/IIIa Inhibitors,Topol E, et al. Lancet. 1999;353:227-231.,Abcixim
2、ab,Eptifibatide,Tirofiban,Fab fragment of a chimeric monoclonal antibody MW 50,000 D,Nonpeptide tyrosine derivative MW 500 D,Cyclic heptapeptide MW 800 D,鼠源性单克隆抗体,合成非肽类,合成肽类,三种静脉GPb/a受体抑制剂的比较,White HD. Am J Cardiol. 1997;80(4A):2B-10B.,GP IIb/IIIa 受体拮抗剂作用机制,Resting platelet,Plaque rupture and platel
3、et adhesion,Platelet activation,Prevention of platelet aggregation,GP IIb/IIIa expression,Fibrinogen,GP IIb/IIIa inhibitor,vWF,vWF,vWF,Agonists,released,Vessel Wall,三种静脉GPb/a受体抑制剂的比较,二、GP IIb/IIIa Inhibitors in ACS,GP IIb/IIIa Inhibitors in ACS,The Prism-Plus Investigators. NEJM 1998;338:1488-97,- D
4、eath or MI at 30 days -,OR 0.70 0.51, 0.96 P=0.03,The PURSUIT Investigators. NEJM 1998;339:436-43,OR 0.90 0.75, 0.98 P=0.04,16.7%,15.6%,14.5%,11.6%,0%,5%,10%,15%,20%,Heparin,Eptifibatide+Heparin,Impact of Early PCI on 30 Day Death/MI,10.2%,10.1%,7.8%,5.9%,0%,5%,10%,15%,Heparin,Tirofiban + Heparin,PR
5、ISM Plus,PURSUIT,DM,Non-DM,5%,10%,6.2%,Placebo,GPIIb/IIIa Inhibitor,4.6%,P=0.007,3.0%,3.0%,P=NS,GPIIb/IIIa Inhibitors in ACS 30-Day mortality results of a Meta-analysis*,Circulation 2001;104:2767-71,* PRISM, PRISM-PLUS, PARAGON A & B, PURSUIT, GUSTO-IV,n= 6,458,n= 23,072,PCI,No PCI,5%,10%,4.0%,Place
6、bo,GPIIb/IIIa Inhibitor,1.2%,P=0.002,6.7%,5.5%,P=0.1,GPIIb/IIIa Inhibitors in Diabetic Patients with ACS,Circulation 2001;104:2767-2771,30-Day Mortalityof a Meta-analysis*,n= 1,279,n= 5,179,* PRISM, PRISM-PLUS, PARAGON A & B, PURSUIT, GUSTO-IV,GUSTO-IV Study Design,Non ST-segment elevation ACS Medic
7、al rx only planned (no angio or PCI) (n=7800),2590 ASA+UFH + Abciximab 24h,2598 ASA+UFH or LMUH +placebo,2612 ASA+UFH + Abciximab 48h,2598,2590,2612,Lancet 2001; 357: 1915-24,P = 0.664,P = 0.235,P = 0.190,GUSTO-IV 30-Day outcomes,Lancet 2001; 357: 1915-24,3.9%,5.1%,8.0%,8.2%,5.6%,3.4%,4.3%,5.9%,9.1%
8、,0%,2%,4%,6%,8%,10%,Death,MI,placebo,Abciximab 24h,Abciximab 48h,Death, MI,* p 0.05,vs placebo,*,*,*,*, 100,000 per L, 50,000 per L,GUSTO-IV safety outcomes,Lancet 2001; 357: 1915-24,*,Benefits of GP IIb/IIIa Inhibitors by Troponin Status in Clinical Trials,Circulation 2001;103:2891-96,TnT-Negative,
9、TnT-Positive,PARAGON-B,PRISM,CAPTURE,Combined,0.125,1,2,0.5,0.125,1,2,0.5,GP IIb/IIIa Better,GP IIb/IIIa Worse,GP IIb/IIIa Better,GP IIb/IIIa Worse,ISAR-REACT 2 Death, MI, or urgent TVR in Subsets With and Without Elevated Troponin Levels (0.03 g/L),0,5,10,15,20,25,30,Days After Randomization,Placeb
10、o Group (N=1010) Abciximab Group (N=1012),Troponin 0.03 g/L Log-Rank p = 0.02,Troponin 0.03 g/L Log-Rank p = 0.98,JAMA 2006; 295:1531-38,%,早期应用有效降低住院死亡率 NRMI注册研究,NRMI-NSTEMI Risk Score,N=60770 NSTEMI患者,住 院 死 亡 率 %,NRMI=National Registry of Myocardial Infarction. Peterson E, et al. J Am Coll Cardiol.
11、 2003;42:45-53,30天死亡 / 心梗绝对下降 (%),1.7% ,2.3% ,用 药 距 离 发 病 的 时 间,越早用药 绝对获益越大 PURSUIT研究: GPIIb/IIIa VS 安慰剂,JAMA. 2000; 284:1549-1558,2009年中国PCI治疗指南 GPb/a受体拮抗剂推荐,三、 GP IIb/IIIa Inhibitors in STEMI,%,GP IIb/IIIa Inhibitors in STEMI,Abciximab and PCI in STEMI Trials 30 Day Endpoint (D, Re-MI, u-TVR),p=0.
12、023,p0.05,p=0.005,PTCA N = 483,Stent N = 401,Stent N = 301,PTCA or Stent N = 2082,Stent N = 400,p=0.038,p=0.01,RAPPORT Abciximab in primary PTCA for STEMI,9.9%,3.3%,5.0%,2.1%,5.4%,1.2%,P=0.003,p=0.098,P=0.01,Circulation 1998;98;734-741,7-day Outcome,RAPPORT,11.2%,5.8%,5.8%,4.6%,6.6%,1.7%,P=0.03,P=0.
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