LI U PHP CH NG NG B NH NHN B NH M CH VNH C CH NH PH U THU T

TS. Nguy n C u L i Trung Tm Tim m ch BV Trung ng Hu

Cc giai o n ti u c u trong hnh thnh c c mu ng

NG GI NGUY C

CH Y MU Ch y mu khi gy t: (T mu t y s ng) Ch y mu trong/ sau ph u thu t

HUY T KH I THUYN T C Huy t kh i-thuyn t c TM Huy t kh i-thuyn t c M

Cc thu c ch ng ng cs trong b nh tim m ch

Khng Vitamine K (AVK) Heparins Heparin khng phn o n (UFH) Heparin TLPTT (LMWH) Fondaparinux Thu c c ch thrombin tr c ti p Khng ti u c u Aspirin (ASA) Clopidogrel Thu c c ch GP IIB/IIIA

d ng

Nguy c huy t kh i - thuyn t c khi khng i u tr AVK

Cao (> 10%/n m) Van hai l c h c, Rung nh v i ti n s t qu hay nhi u y u t nguy c , huy t kh i thuyn t c TM g n y Trung bnh (5-10%/n m) Rung nh v i y u t nguy c ph , ti n s huy t kh i-thuyn t c TM t pht, van MC c h c Th p (< 5%/n m) Rung nh khng c ho c t y u t nguy c , ti n s huy t kh ithuyn t c TM c kh i pht, van tim sinh h c

AVK
Cc ch t AVK ( nh gi tc d ng b ng INR) Giao thoa v i cc y u t ng mu ph thu c Vit.K (II, VII, IX, X, protein C v S) Fenprocoumon (Marcoumar) Warfarine (Marevan) Acenocoumarol (Sintrom) Phenindione (Pindione) Ch t i khng: Vit. K Ph c h p Prothrombin (PPSB: Prothrombin, Proconvertin, y u t Stuart, hemophilia B)

American Heart Association/American College of Cardiology Foundation Guide to Warfarin Therapy - 2010 BN c nguy c huy t kh i thuyn t c th p
(khng c huy t kh i-thuyn t c TM g n y, Rung nh - Li u warfarin c th gi m 4 - 5 ngy tr khi ph u thu t). n thu n...): c ph u thu t (INR 1.3 - 1.5

- Li u duy tr c a warfarin c dng tr l i sau ph u thu t cng v i li u th p heparin (5000 U) ho c LMWH tim DD m i 12g n u c n thi t.

BN v i nguy c huy t kh i thuyn t c trung bnh:

(khng c huy t kh i-thuyn t c TM g n y, Rung nh , van c h c MC) -Li u warfarin c th gi m 4 - 5 ngy tr khi ph u thu t). c ph u thu t (INR 1.3 - 1.5

- Heparine tr c ph u thu t v i li u d phng 5000 U (ho c LMWH 3000 U) tim DD m i 12g. -Heparin (ho c LMWH) v i li u d phng c th c cho l i 12g sau ph u thu t cng v i warfarin v ti p t c trong 4-5 ngy n khi INR t yu c u. N u BN c nguy c cao ch y mu sau ph u thu t th heparin ho c LMWH c th tri n h n 24g ho c lu h n.

BN v i nguy c huy t kh i thuyn t c cao:

(Huy t kh i thuyn t c TM g n y, van hai l c h c, nhi u van tim c h c...) - Li u warfarin c th gi m 4 - 5 ngy tr 1.5 khi ph u thu t). c ph u thu t (INR 1.3 -

-Heparin li u i u tr (15 000 U m i 12g TDD) ho c LMWH (100 U/kg m i 12g TDD), ng ng 24g tr c ph u thu t. - Tr ng h p c n ch ng ng m nh tr c ph u thu t: heparin v i li u t n cng (1300 U/h) chuy n TM lin t c v ng ng 5g tr c ph u thu t, aPTT c th tr v m c c b n tr c ph u thu t. Heparin ho c LMWH c th c dng l i v i li u d phng 12g sau ph u thu t cng v i warfarin v ti p t c cho n khi INR t y uc u

Ng ng AVK bao lu tr

c ph u thu t ?

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  Long history of successful clinical use  Readily monitored by aPTT and ACT

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

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 p inhibits thrombin generation more effectively  Induces release of TFPI vs UFH  Not neutralized by platelet factor 4  Less binding to plasma proteins (eg, acutephase reactant proteins) p 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.

THU C KHNG TI U C U
Acetylsalicylic acid (ASA) Aspirine Thienopyridines Ticlopidin Clopidogrel Prasugrel i khng th th GP IIB/IIIA Abciximab Eptifibatide Tirofiban

Thu c khng TC v ch y mu trong khi ph u thu t

Aspirin: Nguy c ch y mu trong khi ph u thu t th p Khng c n thi t ph i ng ng / Duy tr b nh nhn c nguy c huy t kh i x v a cao D phng tin pht: ng ng 5-7 ngy D phng th pht: khng c n ng ng, ngo i tr : Ph u thu t n i s : 5-7 ngy C t ti n li t tuy n n i soi Ph u thu t d ch knh-vng m c C t amygdale

Thu c khng TC v ch y mu trong khi ph u thu t Thienopyridines T ng ch y mu v c n chuy n mu trong PT tim Ng ng tr c khi ph u thu t Dng l i cng s m cng t t Tr ng h p c bi t: H i ch ng vnh c p, v a m i t stent MV

V n

ng ng thu c khng ti u c u quanh ph u thu t

Ti p t c hai thu c ch ng ti u c u trong v sau ph u

thu t.

Ng ng thu c clopidogrel v chuy n sang thu c khng ti u c u tc d ng ng n hay thu c khng thrombin . Ng ng clopidogrel v dng l i sau ph u thu t.
Brilakis.E.S et al: Perioperative management of patients with coronary stent. JACC 2007, 49: 2145-2150.

V n

ng ng thu c khng ti u c u quanh ph u thu t

Ti p t c hai thu c ch ng ti u c u trong v sau th thu t: - B nh nhn tr i qua ph u thu t s m sau t stent ( nguy c huy t kh i cao). - Nh ng th thu t c th c m mu t i ch nh nh r ng,ph u thu t da, th y tinh th . - C n tham kh o cc ph u thu t vin l ng gi nguy c ch y mu c a ph u thu t, qua cn nh c gi a l i ch v nguy c c a vi c dng thu c. - Khng p d ng cho ph u thu t n u ch y mu d n n h u qu nghim tr ng (PT th n kinh)
Brilakis.E.S et al: Perioperative management of patients with coronary stent. JACC 2007, 49: 2145-2150.

V n

ng ng thu c khng ti u c u quanh ph u thu t

Ng ng thu c clopidogrel v chuy n dng thu c khng ti u c u tc d ng ng n hay thu c ch ng ng: ng dng l c ch glycoprotein IIb/IIIa hay antithrombin. antithrombin.

-Thu c th

- Dng l i clopidogrel cng s m cng t t sau ph u thu t. t. - Th ng dng khi ph i ph u thu t s m (cc PT c nguy c ch y mu cao) sau t stent v c n ph i ng ng clopidogrel. cao) clopidogrel.

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

V n

ng ng thu c khng ti u c u quanh ph u thu t

Ng ng clopidogrel v dng l i sau ph u thu t:

Khi chng ta tin r ng stent n i m c ha huy t kh i r t th p.

v nguy c

 Ph u thu t th n kinh c ng nn theo chi n l

ch y mu cao.

c ny v nguy c

 Khi dng l i thu c (khi h t nguy c ch y mu ), nn dng li u n p

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

Ng ng Clopidogrel lc no ?

K T LU N 1: ang dng AVK

- Ng ng cho n khi INR<1.5.

- Thay th b ng LMWH:
Nguy c cao: li u t n cng 100ui/kg x 2/ngy TDD Nguy c trung bnh: li u trung gian 3000ui x 2/ngy TDD Nguy c th p: li u d phng 50ui/kg x 1/ngy TDD

K T LU N 2: Thu c khng ti u c u
Aspirine: - D phng tin pht: ng ng 5-7 ngy - D phng th pht: khng c n ng ng, ngo i tr PT th n kinh, cc khoang kn Clopidogrel: - Ng ng 5 ngy - Thay b ng cc thu c c ch GP IIB/IIIA tr ng l ng phn t th p ho c LMWH

K T LU N 3:
Nguy c huy t kh i cao: Ph i h p ASA v i c ch GPIIB/IIIA Ph i h p LMWH v i c ch GPIIB/IIIA

Ph u thu t c u n i m ch vnh c p c u: Gi i h n ph u tr ng Off-pump Chuy n TC kh i sau ph u thu t Li th i i m ng x ng c.

XIN C M N