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part of the recommended target range. When non-vitamin K antago-
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part of the recommended target range. When non-vitamin K antago- nist oral anticoagulants are used, the lowest effective tested dose for stroke prevention should be applied. In general, dose reduction below the approved dose is not recommended. Recently, the Open- Label, Randomized, Controlled, Multicenter Study Exploring Two Treatment Strategies of Rivaroxaban and a Dose-Adjusted Oral Vitamin K Antagonist Treatment Strategy in Subjects with Atrial Fibrillation who Undergo Percutaneous Coronary Intervention (PIONEER AF-PCI) study randomized 2124 patients with non- valvular AF, who had undergone PCI with stenting ( 12% STEMI patients), to receive low-dose rivaroxaban [15 mg o.d. (once a day)] plus a P2Y 12 inhibitor (93% clopidogrel) and no aspirin for 12 months, very-low-dose rivaroxaban (2.5 mg b.i.d.) plus DAPT (95% clopidog- rel) for 1, 6, or 12 months, or standard therapy with a dose-adjusted vitamin K antagonist plus DAPT (96% clopidogrel) for 1, 6, or 12 months. 272 The primary safety endpoint (TIMI clinically significant bleeding) was lower in the two groups receiving rivaroxaban. No dif- ference in major bleeding or transfusion was observed across groups. However, this study was underpowered for assessing differences in ischaemic events such as stent thrombosis or stroke rates. Therefore, uncertainty remains regarding the comparative perform- ance of three tested antithrombotic regimens in patients at high stroke and/or stent thrombosis risk. 6.5.2 Elderly patients Owing to the ageing of the population, a higher proportion of elderly patients is expected to present with STEMI. As these patients may present with atypical symptoms, the diagnosis of MI may be delayed or missed. 27 In addition, the elderly have more comorbidities and are less likely to receive reperfusion therapy compared with younger Logistical issues for hospital stay Recommendations Class a Level b It is indicated that all hospitals participating in the care of STEMI patients have a CCU/ICCU equipped to provide all aspects of care for STEMI patients, including treatment of ischaemia, severe heart failure, arrhythmias, and common comorbidities. I C Transfer back to a referring non-PCI hospital Same day transfer should be considered appropri- ate in selected patients after successful primary PCI, i.e. those without ongoing myocardial ischae- mia, arrhythmia, or haemodynamic instability, not requiring vasoactive or mechanical support, and not needing further early revascularization. 263 IIa C Monitoring It is indicated that all STEMI patients have ECG monitoring for a minimum of 24 h. I C Length of stay in the CCU It is indicated that patients with successful reperfu- sion therapy and an uncomplicated clinical course are kept in the CCU/ICCU for a minimum of 24 h whenever possible, after which they may be moved to a step-down monitored bed for an addi- tional 24–48 h. I C Hospital discharge Early discharge (within 48–72 h) should be consid- ered appropriate in selected low-risk patients c if early rehabilitation and adequate follow-up are arranged. 257 , 259 – 262 , 264 , 265 IIa A CCU = coronary care unit; ICCU = intensive cardiac care unit; LVEF = left ven- tricular ejection fraction; PAMI-II, Second Primary Angioplasty in Myocardial Infarction; PCI = percutaneous coronary intervention; STEMI = ST-segment ele- vation myocardial infarction. a Class of recommendation. b Level of evidence. c For example, PAMI-II criteria: age <70 years, LVEF >45%, one- or two-vessel dis- ease, successful PCI and no persistent arrhythmias. ESC Guidelines 143 Downloaded from https://academic.oup.com/eurheartj/article-abstract/39/2/119/4095042 by E-Library Insel user on 07 February 2018 .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. patients. 273 , 274 Elderly patients are also at particular risk of bleeding and other complications from acute therapies because bleeding risk increases with age, renal function tends to decrease, and the preva- lence of comorbidities is high. Observational studies have shown fre- quent excess dosing of antithrombotic therapies in elderly patients. 275 Furthermore, they have a higher risk of mechanical complications. It is key to maintain a high index of suspicion for MI in elderly patients who present with atypical complaints, treating them as rec- ommended, and using specific strategies to reduce bleeding risk; these include paying attention to proper dosing of antithrombotic therapies, particularly in relation to renal function, frailty, or comor- bidities, and using radial access whenever possible. There is no upper age limit with respect to reperfusion, especially with primary PCI. 276 6.5.3 Renal dysfunction Renal dysfunction [estimated glomerular filtration rate (eGFR) <30 mL/min/1.73 m 2 ] is present in approximately 30–40% of patients with ACS and is associated with a worse prognosis and increased risk of in-hospital complications. 277 Owing to differences in presentation (less frequent presentation with chest pain and fewer typical ECG signs) diagnosis may be delayed. Although decisions on reperfusion in patients with STEMI have to be made before any assessment of renal function is available, it is important to estimate the GFR as soon as possible. The type and dose of antithrombotic agent (see Table 9 ) and the amount of con- trast agent should be considered based on renal function. 277 ACS patients with chronic kidney disease (CKD) receive frequently excess dosing with antithrombotics, contributing to the increased bleeding risk. 275 Consequently, in patients with known or anticipated reduc- tion of renal function, several antithrombotic agents should either be withheld or their doses reduced appropriately. Ensuring proper hydration during and after primary PCI and limiting the dose of con- trast agents, preferentially low-osmolality contrast agents, are impor- tant steps in minimizing the risk of contrast-induced nephropathy. 1 6.5.4 Non-reperfused patients Patients who, for specific reasons (e.g. long delay), fail to receive reper- fusion therapy within the recommended time (first 12 h) should imme- diately be evaluated clinically to rule out the presence of clinical, Table 9 Recommended doses of antithrombotic agents in the acute care of patients with chronic kidney disease tải về 4.91 Mb. Chia sẻ với bạn bè của bạn:
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