Professional Documents
Culture Documents
2012
funcii neidentificate anterior n inflamaie i injuria vascular, iar strategiile
antiplachetare ar putea influena proteinele-semnal derivate din plachete,
cu rol n rspunsurile inflamatorii i/sau proliferative.
2012
rapid i ntreruperea rapid a inhibiiei plachetare i care nu necesit ac-
tivare metabolic hepatic: ticagrelor (un agent oral), cangrelor (un agent
intravenos) i elinogrel (disponibil att ca agent intravenos i oral).
Ticagrelor este absorbit rapid i se transform enzimatic n cel puin un
metabolit activ, concentraia plasmatic de vrf i inhibiia plachetar ma-
xim se obine la 1-3 ore de la administrare, iar timpul de semivia plasma-
tic este 6-13 h ceea ce impune o administrare de dou ori pe zi.
Inhibitorii de fosfodiesteraz
Dipiridamolul este un derivat de pirimidopirimidin cu efecte vasodila-
tatoare i (subiect de controverse) antiplachetare. Eficiena clinica a dipiri-
damol-ului, singur sau n asociere cu aspirina a fost cercetata n mai multe
trialuri randomizate (ESPS-2, ESPRIT, PRoFESS), la pacieni cu AVC acut sau
recent. Aceste studii au artat ca asocierea dipiridamolului cu aspirin scade
riscul unui eveniment vascular major n medie de 20%, dar crete adresabili-
tatea pacienilor n departamentul de urgen din cauza efectelor secundare
- cefalee important i hemoragii severe(11).
Cilostazol este un inhibitor reversibil de fosfodiesteraz tip III cu efecte
vasodilatatoare i antiplachetare. Adugat unei combinaii standard cu aspi-
rina i clopidogrel, cilostazol n doz de 100 mg x 3/zi poteneaz inhibarea
agregrii plachetare ADP-induse.
43
Formula Drog activ Pro-drog, limitat Pro-drog, nu Drog activ
de metabolizare este limitat de
metabolizare
Doza de ncr- 150300 mg 600 sau 300 mg 60 mg (p.o.) 180 mg (p.o.)
care (p.o.) (p.o.)
Doza de ntre- 75-100 mg/zi 150/75 mg/zi 10 mg/zi 90 mg x 2/zi
inere
Reversibilitate Nu Nu Nu Da
efect
Debutul efec- 5-30 min 2-4 ore 30 min 30 min
tului
Durata efectului 7-10 zile 3-10 zile 5-10 zile 3-4 zile
De ntrerupt 7 zile 5 zile 7 zile 5 zile
nainte de o
intervenie
chirurgical
major cu:
2012
bitioNThrombolysis In Myocardial Infarction 38 - TRITONTIMI 38, date
pentru ticagrelor n principal din PLATelet inhibition and patient Outcomes
- PLATO) precum i un anticoagulant parenteral. Aspirina se va administra
per os (preferabil 150300 mg) sub form masticabil sau i.v. la pacienii
care nu pot nghii (preferabil un bolus de 80150 mg). Blocantele recepto-
rilor-ADP preferai sunt prasugrel (60 mg per os doza de ncrcare, 10 mg
doza de ntreinere) sau ticagrelor (180 mg p.o. doza de ncrcare, 9 mg x
2/zi doza de ntreinere). Prasugrel este contraindicat n cazul pacienilor
cu accident vascular cerebral constituit sau tranzitor i nu este n general
recomandat n cazul pacienilor peste 75 ani i a celor subponderali (sub 60
kg), ns dac totui se administreaz doza de ncrcare rmne aceeai dar
44 cea de ntreinere se va reduce la 5 mg. Ticagrelor poate determina apariia
unei dispnei tranzitorii la debutul administrrii sale i este asociat cu apa-
riia unei bradicardii asimptomatice n prima sptmn de administrare.
Niciunul dintre cei doi ageni antiplachetari nu se va administra la pacienii
cu accident vascular hemoragic n antecedente sau la pacienii cu o afec-
tare hepatic medie-sever. Dac aceti ageni nu sunt disponibili se poate
recurge la administrarea de clopidogrel 600 mg doza de ncrcare i 150
mg doza de ntreinere (superioar dozelor 300/75 mg, conform Optimal
Antiplatelet Strategy for Interventions - OASIS 7. Toi aceti ageni vor fi
utilizai cu precauie n cazul pacienilor cu risc nalt de sngerare sau cu
anemie semnificativ.
2012
Infarctul miocardic acut fr supradenivelare de segment ST (NSTEMI)
(4)
Tratamentul antiplachetar trebuie administrat ct mai precoce posibil, nda-
t ce diagnosticul NSTEMI este stabilit att pentru a reduce riscul de apari-
ie a complicaiilor ischemice acute ct I a evenimentelor aterotrombotice
recurente.
2012
(se continu pe toat durata vieii pacientului) i inhibitorul P2Y12 (se con-
tinu timp de 12 luni, dac nu exist un risc hemoragic nalt).
1. Criterii majore
Orice hemoragie intracranian (cu excepia microhemoragiilor <10 mm
evidente doar la evaluarea prin gradient-echo MRI)
Semne clinice evidente de hemoragie asociate cu o reducere a hemoglo-
binei cu 5 g/dl sau a valorii absolute a hematocritului cu 15%
Hemoragii fatale (hemoragii care genereaz direct decesul n primele 7
zile).
2. Criterii minore
Semne clinice evidente de hemoragie (inclusiv imagistic), determinnd
reducerea hemoglobinei cu 3 pn la <5 g/dl sau a valorii absolute a
hematocritului cu 10%
Hemoragii ne-exteriorizate: reducerea cu 4 g/dl a hemoglobinei sau a
hematocritului cu 12%
Orice semn clinic evident de hemoragie care ndeplinete unul dintre
criteriile urmtoare, dar nu pe acelea pentru evenimente hemoragice
majore sau minore aa cum au fost acestea definite mai sus)
Necesit intervenie (tratament medical sau chirurgical pentru a ntre-
rupe sau trata hemoragia, inclusiv ntreruperea temporar/permanent
sau modificarea dozei medicamentului)
Care determin sau prelungete spitalizarea
2012
Care necesit o evaluare prompt (care determin o consultaie nepro-
gramat sau efectuarea unor teste diagnostice de laborator sau ima-
gistice)
3. Criterii minime
Orice episod hemoragic care nu ndeplinete criteriile de mai sus;
Orice semn clinic evident de hemoragie (inclusiv imagistic) asociat cu o
scdere cu < 3 g/dl a hemoglobinei sau o reducere cu < 9% a hemato-
critului.
Bibliografie:
1. Patrono C, Andreotti F, Arnesen H, Badimon L, Baigent C, Collet JP, De Caterina R, Gulba D, Huber K,
Husted S, Kristensen SD, Morais J, Neumann FJ, Rasmussen LH, Siegbahn A, Steg PG, Storey RF, Van
deWerf F, Verheugt F. Antiplatelet agents for the treatment and prevention of atherothrombosis. Eur
Heart J 2011; 32: 29222932.
2. Wijns W, Kolh P, Danchin N, et al. Guidelines on myocardial revascularization: the Task Force on Myo-
cardial Revascularization of the European Society of Cardiology (ESC) and the European Association for
Cardio-Thoracic Surgery (EACTS). Eur Heart J 2010; 31: 25012555.
3. Steg PG, James SK, Atar D, Badano LP, Blomstrom Lundqvist C, Borger MA, Di Mario C, Dickstein K,
Ducrocq G), Fernandez-Aviles F, Gershlick AH, Giannuzzi P, Halvorsen S, Huber K, Juni P, Kastrati A,
Knuuti J, Lenzen M, Mahaffey KW, Valgimigli M, vant Hof A, Widimsky P, Zahger D. ESC Guidelines for
the management of acute myocardial infarction in patients presenting with ST-segment elevation: The
Task Force on the management of ST-segment elevation acute myocardial infarction of the European
Society of Cardiology (ESC) Eur Heart J (2012) 0(2012): ehs215v1-ehs215
4. Hamm CW, Bassand JP, Agewall S, et al. ESC guidelines for the management of acute coronary
syndromes in patients presenting without persistent ST-segment elevation: the Task Force for the
management of acute coronary syndromes (ACS) in patients presenting without persistent ST-segment
elevation of the European Society of Cardiology (ESC). Eur Heart J 2011; 32: 29993054.
5. Lip GYH, Ponikowski P, Andreotti F, Anker SD, Filippatos G, Homma S, Morais J, Pullicino P, Rasmussen
LH, Marin F, Lane DA. Thrombo-embolism and antithrombotic therapy for heart failure in sinus rhythm.
A Joint Consensus Document from the ESC Heart Failure Association and the ESC Working Group on
Thrombosis Eur J Heart Fail 2012; 14: 681-695.
6. Lip GY, Huber K, Andreotti F, et al. Antithrombotic management of atrial fibrillation patients presenting
with acute coronary syndrome and/or undergoing coronary stenting: executive summary a consensus
document of the European Society of Cardiology Working Group on Thrombosis, endorsed by the Euro-
pean Heart Rhythm Association (EHRA) and the European Association of Percutaneous Cardiovascular
Interventions (EAPCI). Eur Heart J 2010; 31: 13111318
7. Korte W, Cattaneo M, Chassot PG, Eichinger S, von Heymann C, Hofmann N, Rickli H, Spannagl M,
Ziegler B, Verheugt F, Huber K. Peri-operative management of antiplatelet therapy in patients with
coronary artery disease: joint position paper by members of the working group on Perioperative
Haemostasis of the Society on Thrombosis and Haemostasis Research (GTH), the working group on
Perioperative Coagulation of the Austrian Society for Anesthesiology, Resuscitation and Intensive Care
(GARI) and the Working Group Thrombosis of the European Society for Cardiology (ESC). Thromb
Haemost 2011; 105: 743-9.
8. Hchtl T, Sinnaeve PR, Adriaenssens T, Huber K. Oral antiplatelet therapy in acute coronary syndromes:
update 2012. Eur Heart J: Acute Cardiovascular Care 2012 1: 79.
9. Mehran R, Rao SV, Bhatt DL, Gibson CM, Caixeta A, Eikelboom J et al. Standardized bleeding definitions
for cardiovascular clinical trials: a consensus report from the bleeding academic research consortium.
Circulation 2011; 123: 2736-47.
2012
10. Schiele F, Meneveau N. The role of the interventional cardiologist in selecting antiplatelet agents in
acute coronary syndromes: a 10-question strategy European Heart Journal: Acute Cardiovascular Care
2012; 1: 170-176.
11. Eikelboom JW, Hirsh J, Spencer FA, Baglin TP, Weitz JI. Antithrombotic Therapy and Prevention of
Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines,
CHEST / 141 / 2 / Febr, 2012 Suppl.
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