醫(yī)學(xué)免費(fèi)論文:雙重抗血小板治療并發(fā)上消化道出血的風(fēng)險(xiǎn)及治療

上述資料提示對(duì)植入支架的患者應(yīng)盡可能繼續(xù)行抗血小板治療，但要平衡支架內(nèi)血栓形成和持續(xù)出血或再發(fā)出血之間的危險(xiǎn)。支架內(nèi)血栓的危害與支架位置、治療血管供血區(qū)存活心肌數(shù)量等因素有關(guān)。而UGH患者再出血和死亡風(fēng)險(xiǎn)可通過臨床表現(xiàn)和內(nèi)鏡檢查結(jié)果來綜合評(píng)估，即Rockall評(píng)分系統(tǒng)，<3分預(yù)后良好，>8分有較高的死亡率。隨著治療水平的提高，該評(píng)分系統(tǒng)可能輕度高估再出血風(fēng)險(xiǎn)[19]。對(duì)于近期(金屬裸支架4周，藥物涂層支架6個(gè)月)植入支架后出現(xiàn)嚴(yán)重上消化道出血的患者，建議停用肝素、比伐盧定等抗凝藥及GPⅡb/Ⅲa受體拮抗劑，除非有進(jìn)行性出血，一般不需要輸注血小板。根據(jù)Rockall評(píng)分調(diào)整抗血小板治療，積分≤4，中斷抗血小板治療的死亡風(fēng)險(xiǎn)大于UGH，繼續(xù)行雙重抗血小板治療;積分≥5，繼續(xù)口服氯吡格雷，停用阿司匹林48 h再評(píng)估，2周內(nèi)加用阿司匹林治療;持續(xù)出血者應(yīng)停用所有抗血小板藥物，每天評(píng)估出血狀態(tài)，1～2周內(nèi)加用氯吡格雷[3,23]。

5 總 結(jié)

PCI術(shù)后患者接受雙重抗血小板治療，使上消化道黏膜損傷和出血的病例明顯增加。治療過程中有時(shí)中斷抗血小板治療，使得支架內(nèi)血栓形成風(fēng)險(xiǎn)顯著增加，加上嚴(yán)重消化道出血本身的風(fēng)險(xiǎn)，使得該類患者死亡率高。因此，治療過程中要權(quán)衡支架內(nèi)血栓和嚴(yán)重出血所帶來的危險(xiǎn)，但目前對(duì)此還存在許多分歧，仍需要進(jìn)一步的隨機(jī)臨床試驗(yàn)來制定合理的治療方案。

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