Heparin trọng lượng phân tử thấp trong hội chứng mạch vành cấp

HEPARIN TRỌNG LƯỢNG PHÂN TỬ THẤP TRONG HỘI CHỨNG MẠCH VÀNH CẤP: Những chia sẻ từ lâm sàng PGS TS Nguyễn Văn Trí Hội chứng mạch vành cấp Nghi ngờ HCMVC Lúc nhập viện Phòng cấp cứu Non-ST  ST  + Trong BV ĐTN KÔĐ Adapted from Braunwald et al J Am Coll Cardiol 2002 + NMCT non Q + + NMCT có sóng Q + = dấu ấn/men tim dương tính 06-Mar-17 TS.BS DO QUANG HUAN 06-Mar-17 TS.BS DO QUANG HUAN N=12.142 06-Mar-17 TS.BS DO QUANG HUAN 06-Mar-17 TS.BS DO QUANG HUAN 06-Mar-17 HIT 06-Mar-17 TS.BS DO QUANG HUAN 06-Mar-17 TS.BS DO QUANG HUAN Heparin NMCT cấp *1948-1997:  36 nghiên cứu  thử nghiệm lâm sàng  nghiên cứu so sánh với Heparin placebo ) • GISSI-2, ISIS-3, GUSTO-1: • 94.810 BN dùng tiêu sợi huyết + Heparin 06-Mar-17 Death or Complication of MI Death, resuscitated cardiac arrest, recurrent MI/ACS, Urg Revasc, stroke, peripheral or pulmonary embolism 0.15 Log-Rank Test UFH ENOX 12.4% 0.10 i 37% 0.05 7.8% 06-Mar-17 p=0.02 0.00 Death or Complication of MI rate 30d rate (%) 10 15 Days 20 25 30 0.04 i 40% 0.02 3.8% 10 15 Days 06-Mar-17 20 25 30 0.10 0.08 p=0.049 7.0% 0.06 6.3% i 42% 0.04 0.06 6.3% UFH ENOX Log-Rank Test 3.8% 4.0% 0.02 p=0.08 30d rate (%) 0.00 Log-Rank Test Death or resuscitated cardiac arrest rate 0.10 0.08 UFH ENOX 0.00 Death rate Death or resuscitated cardiac arrest Death (any) 10 15 Days 20 25 30 Death, Complication of MI or Major bleeding Net clinical benefit 16 % of patients 14 RRR = 32% P = 0.03 12 10 10,2 06-Mar-17 15 UFH ENOX STEEPLE Trial 3528 pts with non-emergent single or multi-vessel PCI IV enoxaparin 0.5 mg/kg n=1070 IV enoxaparin 0.75 mg/kg n=1228 ACT – adjusted UFH Target ACT 200-300 With GP IIb/IIIa Target ACT 300-350 if no GP IIb/IIIa n=1230 Primary Endpoint: Major / minor bleeding (non-CABG) at 48 hrs post-PCI Secondary Endpoints: - Percent reaching target anticoagulation levels at start and end of PCI - Composite of major bleed (48 hrs), mortality, MI, Urg TVR at 30 days 06-Mar-17 Montalescot: NEJM 2006;355:1006-1017 STEEPLE Trial: Primary Endpoint Non-CABG Major or Minor Bleeding at 48 hrs 20% Enox 0.5 mg/kg Enox 0.75 mg/kg UFH 15% p=0.014 vs UFH 10% 6.0% p=0.052 vs UFH 8.7% 6.6% 5% 0% Lower bleeding rate was observed overall and in the GP IIb/IIIa subgroup 06-Mar-17 Montalescot: NEJM 2006;355:1006-1017 STEEPLE Trial Analysis of Major Bleeding Enox 0.5 mg/kg Enox 0.75 mg/kg UFH 5% 4% p=0.005 vs UFH p=0.007 vs UFH 3% 2% 1.2% 2.8% 1.2% 1% 0% 57% lower with Enoxaparin 06-Mar-17 Montalescot: NEJM 2006;355:1006-1017 STEEPLE Trial: Secondary Endpoint Patients reaching target anticoagulation levels at the start and end of procedure Enox 0.5 mg/kg 100% 80% 60% 40% 20% Enox 0.75 mg/kg UFH 91.7% 78.8% p