DEMA-CVN

GII THIU

CC TI BO CO TI HI NGH TIM MCH MIN TRUNG- TY NGUYN M RNG LN TH VI TI BUN MA THUT THNG 8 NM 2011

LIU PHP CHNG NG BNH NHN BNH MCH VNH C CH NH PHU THUT
TS. Nguyn Cu Li Trung Tm Tim mch BV Trung ng Hu

Cc giai on tiu cu trong hnh thnh cc mu ng

LNG GI NGUY C

CHY MU Chy mu khi gy t: (T mu ty sng)

HUYT KHI THUYN TC Huyt khi-thuyn tc TM Huyt khi-thuyn tc M

Chy mu trong/ sau phu thut

Cc thuc chng ng c s dng trong bnh tim mch

Khng Vitamine K (AVK) Heparins Heparin khng phn on (UFH) Heparin TLPTT (LMWH) Fondaparinux Thuc c ch thrombin trc tip
Khng tiu cu Aspirin (ASA) Clopidogrel Thuc c ch GP IIB/IIIA

Nguy c huyt khi - thuyn tc khi khng iu tr AVK

Cao (> 10%/nm) Van hai l c hc, Rung nh vi tin s t qu hay nhiu yu t nguy c, huyt khi thuyn tc TM gn y Trung bnh (5-10%/nm) Rung nh vi yu t nguy c ph, tin s huyt khi-thuyn tc TM t pht, van MC c hc
Thp (< 5%/nm) Rung nh khng c hoc t yu t nguy c, tin s huyt khithuyn tc TM c khi pht, van tim sinh hc

AVK
Cc cht AVK (nh gi tc dng bng INR) Giao thoa vi cc yu t ng mu ph thuc Vit.K (II, VII, IX, X, protein C v S) Fenprocoumon (Marcoumar) Warfarine (Marevan) Acenocoumarol (Sintrom) Phenindione (Pindione) Cht i khng: Vit. K Phc hp Prothrombin (PPSB: Prothrombin, Proconvertin, yu t Stuart, hemophilia B)

American Heart Association/American College of Cardiology Foundation Guide to Warfarin Therapy - 2010 BN c nguy c huyt khi thuyn tc thp
(khng c huyt khi-thuyn tc TM gn y, Rung nh n thun...): - Liu warfarin c th gim 4 - 5 ngy trc phu thut (INR 1.3 - 1.5 khi phu thut). - Liu duy tr ca warfarin c dng tr li sau phu thut cng vi liu thp heparin (5000 U) hoc LMWH tim DD mi 12g nu cn thit.

 BN

vi nguy c huyt khi thuyn tc trung bnh:

(khng c huyt khi-thuyn tc TM gn y, Rung nh, van c hc MC)

-Liu warfarin c th gim 4 - 5 ngy trc phu thut (INR 1.3 - 1.5 khi phu thut). - Heparine trc phu thut vi liu d phng 5000 U (hoc LMWH 3000 U) tim DD mi 12g. -Heparin (hoc LMWH) vi liu d phng c th c cho li 12g sau phu thut cng vi warfarin v tip tc trong 4-5 ngy n khi INR t yu cu. Nu BN c nguy c cao chy mu sau phu thut th heparin hoc LMWH c th trin hn 24g hoc lu hn.

BN vi nguy c huyt khi thuyn tc cao:

(Huyt khi thuyn tc TM gn y, van hai l c hc, nhiu van tim c hc...) - Liu warfarin c th gim 4 - 5 ngy trc phu thut (INR 1.3 1.5 khi phu thut). -Heparin liu iu tr (15 000 U mi 12g TDD) hoc LMWH (100 U/kg mi 12g TDD), ngng 24g trc phu thut. - Trng hp cn chng ng mnh trc phu thut: heparin vi liu tn cng (1300 U/h) chuyn TM lin tc v ngng 5g trc phu thut, aPTT c th tr v mc c bn trc phu thut. Heparin hoc LMWH c th c dng li vi liu d phng 12g sau phu thut cng vi warfarin v tip tc cho n khi INR t yu cu

Ngng AVK bao lu trc phu thut ?

Fenprocoumon (Marcoumar) 10 ngy (t1/2: 4-7 ngy) Warfarin (Marevan) 7 ngy (t1/2: 20-60 gi) Acenocoumarol (Sintrom) 4 ngy (t1/2: 8-11 gi)

Unfractionated Heparin
Advantages
Immediate anticoagulation Multiple sites of action in coagulation cascade

Disadvantages
Indirect thrombin inhibitor so does not inhibit clot-bound thrombin Nonspecific binding to: Serine proteases Endothelial cells (can lead to variability in level of anticoagulation) Reduced effect in ACS Inhibited by PF-4 Causes platelet aggregation Nonlinear pharmacokinetics Risk of HIT

Long history of successful clinical use

Readily monitored by aPTT and ACT

Hirsh J, et al. Circulation. 2001;103:2994-3018. aPTT = activated partial thromboplastin time; ACT = activated coagulation time; PF-4 = platelet factor 4; HIT = heparin-induced thrombocytopenia.

Low-Molecular-Weight Heparin
Advantages
Increased anti-Xa to anti-IIa activity inhibits thrombin generation more effectively Induces release of TFPI vs UFH Not neutralized by platelet factor 4 Less binding to plasma proteins (eg, acute-phase reactant proteins) more consistent anticoagulation Lower rate of HIT vs UFH Lower fibrinogen levels Easy to administer (SC administration) Long history of clinical studies and experience, FDA-approved indications Monitoring typically unnecessary

Disadvantages
Indirect thrombin inhibitor Less reversible Difficult to monitor (no aPTT or ACT) Renally cleared Long half-life Risk of HIT

Hirsh J, et al. Circulation. 2001;103:2994-3018. TFPI = tissue factor pathway inhibitor; UFH = unfractionated heparin; SC = subcutaneous; aPTT = activated partial thromboplastin time; ACT = activated coagulation time.

THUC KHNG TIU CU

Acetylsalicylic acid (ASA) Aspirine Thienopyridines Ticlopidin Clopidogrel Prasugrel

i khng th th GP IIB/IIIA Abciximab Eptifibatide Tirofiban

Thuc khng TC v chy mu trong khi phu thut

Aspirin: Nguy c chy mu trong khi phu thut thp Khng cn thit phi ngng / Duy tr bnh nhn c nguy c huyt khi x va cao D phng tin pht: ngng 5-7 ngy D phng th pht: khng cn ngng, ngoi tr: Phu thut ni s: 5-7 ngy Ct tin lit tuyn ni soi Phu thut dch knh-vng mc Ct amygdale

Thuc khng TC v chy mu trong khi phu thut

Thienopyridines Tng chy mu v cn chuyn mu trong PT tim Ngng trc khi phu thut Dng li cng sm cng tt Trng hp c bit: Hi chng vnh cp, va mi t stent MV

Vn ngng thuc khng tiu cu quanh phu thut

Tip tc hai thuc chng tiu cu trong v sau phu

thut. Ngng thuc clopidogrel v chuyn sang thuc khng tiu cu tc dng ngn hay thuc khng thrombin . Ngng clopidogrel v dng li sau phu thut.

Brilakis.E.S et al: Perioperative management of patients with coronary stent. JACC 2007, 49: 2145-2150.

Vn ngng thuc khng tiu cu quanh phu thut

Tip tc hai thuc chng tiu cu trong v sau th thut:

- Bnh nhn tri qua phu thut sm sau t stent ( nguy c huyt khi cao). - Nhng th thut c th cm mu ti ch nh nh rng,phu thut da, thy tinh th. - Cn tham kho cc phu thut vin lng gi nguy c chy mu ca phu thut, qua cn nhc gia li ch v nguy c ca vic dng thuc. - Khng p dng cho phu thut nu chy mu dn n hu qu nghim trng (PT thn kinh)
Brilakis.E.S et al: Perioperative management of patients with coronary stent. JACC 2007, 49: 2145-2150.

Vn ngng thuc khng tiu cu quanh phu thut

Ngng thuc clopidogrel v chuyn dng thuc khng tiu cu tc dng ngn hay thuc chng ng: -Thuc thng dng l c ch glycoprotein IIb/IIIa hay antithrombin. - Dng li clopidogrel cng sm cng tt sau phu thut. - Thng dng khi phi phu thut sm (cc PT c nguy c chy mu cao) sau t stent v cn phi ngng clopidogrel.

Brilakis.E.S et al: Perioperative management of patients with coronary stent. JACC 2007, 49: 2145-2150.

Vn ngng thuc khng tiu cu quanh phu thut

Ngng clopidogrel v dng li sau phu thut :
Khi chng ta tin rng stent ni mc ha y v nguy c huyt khi rt thp.

Phu thut thn kinh cng nn theo chin lc ny v nguy c

chy mu cao. Khi dng li thuc (khi ht nguy c chy mu ), nn dng liu np

600 mg clopidogrel.
Brilakis.E.S et al: Perioperative management of patients with coronary stent. JACC 2007, 49: 2145-2150.

Ngng Clopidogrel lc no ?

KT LUN 1: ang dng AVK

- Ngng cho n khi INR<1.5. - Thay th bng LMWH:
Nguy c cao: liu tn cng 100ui/kg x 2/ngy TDD Nguy c trung bnh: liu trung gian 3000ui x 2/ngy TDD Nguy c thp: liu d phng 50ui/kg x 1/ngy TDD

KT LUN 2: Thuc khng tiu cu

Aspirine: - D phng tin pht: ngng 5-7 ngy - D phng th pht: khng cn ngng, ngoi tr PT thn kinh, cc khoang kn Clopidogrel: - Ngng 5 ngy - Thay bng cc thuc c ch GP IIB/IIIA trng lng phn t thp hoc LMWH

KT LUN 3:
Nguy c huyt khi cao: Phi hp ASA vi c ch GPIIB/IIIA Phi hp LMWH vi c ch GPIIB/IIIA

Phu thut cu ni mch vnh cp cu: Gii hn phu trng Off-pump Chuyn TC khi sau phu thut Li thi im ng xng c.

XIN CM N