Taw qhia
Thaum lub sij hawm kho mob plawv thiab lwm yam percutaneous coronary intercession (PCI) methodology, anticoagulants zoo li heparin thiabbivalirudin yog siv los ua kom cov ntshav coagulating. Txawm hais tias lawv ua haujlwm rau tib lub hom phiaj, cov txheej txheem ntawm kev nqis tes ua, kev ruaj ntseg profiles, thiab kev siv tshuaj kho mob ntawm ob hom tshuaj sib txawv heev. Peb yuav tshuaj xyuas qhov sib txawv ntawm cov heparin thiab Bivalirudin hauv qhov blog nkag, zeroing ntawm lawv cov kev ua ub no, kev phom sij ntawm kev tuag, thiab cov tsos mob tshwm sim.
Cov txheej txheem ntawm kev ua ntawm heparin thiab Bivalirudin txawv li cas?
Qhov thib ob, qhov kev pheej hmoo ntawm HIT raug txo vim tias Bivalirudin tsis khi rau PF4 lossis lwm cov ntshav proteins. Qhov no yog ib qho txiaj ntsig zoo tshaj plaws ntawm heparin, vim HIT tuaj yeem yog qhov txaus ntshai uas yuav tsum tau ua tiav luv luv ntawm kev kho mob heparin thiab xaiv cov tswv yim anticoagulation.
Thib peb, Bivalirudin muaj kev txwv ntau dua ib nrab-lub neej sawv tawm ntawm heparin, uas txiav txim siab thim rov qab sai ntawm nws cov tshuaj tiv thaiv coagulant thaum sawv ntxov. Bivalirudin muaj ib nrab nyob ntawm kwv yees li 25 feeb, txawm hais tias heparin muaj ib nrab ntawm 1-2 teev. Thaum nws yog ib qho tsim nyog yuav tsum tau ua kev phais sai lossis sai rov qab los tiv thaiv coagulation, xws li thaum muaj teeb meem los ntshav, qhov kev ua haujlwm luv luv no yog qhov tshwj xeeb tshaj yog pab tau.Heparin thiab Bivalirudin yog ob qho tshuaj tiv thaiv coagulant, tab sis lawv ua hauj lwm los ntawm cov txheej txheem sib txawv los tiv thaiv cov ntshav txhaws. Rau cov kws kho mob kom paub txog kev txiav txim siab txog cov tshuaj twg los siv hauv cov xwm txheej tshwj xeeb, nws yog qhov tseem ceeb kom nkag siab txog cov kev sib txawv no.
Heparin yog ib tug circuitous thrombin inhibitor uas ua haujlwm los ntawm kev txwv rau thiab txhim kho qhov kev txiav txim ntawm antithrombin III, ib tug yam ntxwv anticoagulant protein nyob rau hauv cov ntshav. Antithrombin III ces inactivates ob peb coagulation yam, xws li thrombin (factor IIa) thiab factor Xa, yog li inhibiting lub coagulation cascade. Heparin cov nyhuv anticoagulant yog kho los ntawm qhov kev tsis ncaj ncees no, uas yuav tsum muaj cov tshuaj antithrombin III rau nws cov haujlwm.
Ib qho ntawm cov yam ntxwv tseem ceeb ntawm heparin yog nws qhov kev txwv tsis pub muaj cov protein ntau hauv cov ntshav, suav nrog platelet factor 4 (PF4). Qhov kev txwv tsis meej no tuaj yeem ua rau muaj kev npaj ntawm heparin-PF4 cov tsev, uas hauv qee cov neeg mob tuaj yeem ua rau heparin-actuated thrombocytopenia (HIT).
Hloov pauv, Bivalirudin yog ib qho thrombin inhibitor tam sim ntawd uas txuas ncaj qha rau thrombin thiab thaiv nws qhov kev ua. Bivalirudin yog ib qho hluavtaws 20-amino acid peptide uas zoo li fibrinogen, thrombin lub ntuj substrate. Nws tiv thaiv thrombin los ntawm cleaving fibrinogen rau hauv fibrin, thawj feem ntawm cov ntshav txhaws, los ntawm binding reversibly rau nws active site. Los ntawm ncaj qha txwv tsis pub thrombin, Bivalirudin tiag tiag intrudes ntawm txoj kev ib txwm dhau los ntawm coagulation overflow, tsis muaj teeb meem dab tsi hauv lub hauv paus actuating system (inherent los yog extraneous txoj kev).
Direct mechanism ntawm kev txiav txim ntawmBivalirudinmuaj ntau yam zoo dua heparin. Ua ntej, Bivalirudin muab cov lus teb ua kom pom tseeb dua cov tshuaj tiv thaiv coagulant piv rau heparin. Heparin txoj kev txav tuaj yeem cuam tshuam los ntawm cov ntsiab lus sib txawv, piv txwv li, qib ntawm antithrombin III hauv cov ntshav, muaj cov protein uas txwv tsis pub heparin, thiab kev hloov pauv hauv kev npaj heparin. Cov yam ntxwv no tuaj yeem ua rau muaj qhov tsis sib xws thiab tsis tuaj yeem tshwm sim los ntawm cov tshuaj tiv thaiv coagulant, yuav tsum tau saib xyuas ntau zaus thiab hloov tshuaj. Hauv qhov sib piv, Bivalirudin qhov ncaj qha thrombin inhibition ua rau muaj kev cuam tshuam ntau dua thiab pom tau tias cov tshuaj tiv thaiv coagulant, nrog tsawg xav tau kev saib xyuas.
Thib ob, vim tias Bivalirudin tsis khi rau PF4 lossis lwm cov ntshav protein, qhov kev pheej hmoo ntawm HIT raug txo. Qhov no yog qhov txiaj ntsig tseem ceeb tshaj plaws ntawm heparin, vim tias HIT tuaj yeem ua rau muaj kev phom sij txaus ntshai uas yuav tsum muaj kev kho mob heparin sai sai thiab xaiv cov txheej txheem tiv thaiv coagulation.
Thib peb, Bivalirudin muaj qhov txwv ib nrab-lub neej sib piv nrog heparin, uas txiav txim siab nrawm nrawm ntawm nws cov tshuaj tiv thaiv coagulant tom qab nres. Heparin muaj ib nrab-lub neej ntawm 1-2 teev, whereas bivalirudin muaj ib nrab-lub neej ntawm kwv yees li 25 feeb. Lub sijhawm luv luv ntawm kev ua haujlwm no yog qhov tseem ceeb tshwj xeeb tshaj yog thaum nws tsim nyog los ua kev phais sai lossis thim rov qab anticoagulation sai, xws li thaum muaj teeb meem los ntshav.
Hauv kev txiav txim siab, cov txheej txheem ntawm kev ua ntawm heparin thiab bivalirudin txawv, nrog bivalirudin khi ncaj qha rau thrombin thiab heparin ua tus tsis ncaj thrombin inhibitor uas yuav tsum muaj antithrombin III rau nws cov haujlwm. Cov kev sib txawv ntawm cov khoom siv no hloov mus rau cov txiaj ntsig tsis muaj txiaj ntsig thiab kev cuam tshuam rau txhua yam tshuaj, nrog Bivalirudin muab cov tshuaj tiv thaiv tsis txaus ntseeg ntau dua, kev phom sij qis ntawm HIT, thiab ntau dua ib nrab-lub neej sib piv nrog heparin.
Puas yog Bivalirudin muaj kev nyab xeeb dua li heparin ntawm kev pheej hmoo los ntshav?
Los ntshav yog ib qho teeb meem loj thiab muaj feem cuam tshuam loj ntawm txoj kev kho anticoagulant, thiab txo qis kev pheej hmoo los ntshav yog qhov tseem ceeb thaum xaiv ntawm heparin thiab Bivalirudin. Ob cov tshuaj no cov teebmeem ntawm los ntshav tau muab piv rau ntau qhov kev tshawb fawb, tshwj xeeb tshaj yog nyob rau hauv cov ntsiab lus ntawm percutaneous coronary intervention (PCI).
REPLACE{{0}} kev sim, uas suav nrog ntau dua 6,000 cov neeg mob uas tau txais PCI, pom tau tias Bivalirudin cuam tshuam nrog kev pheej hmoo ntawm cov los ntshav loj dua piv rau heparin ntxiv rau glycoprotein IIb/IIIa inhibitor. (GPI). Hauv qhov kev tshuaj xyuas no, qhov tshwm sim ntawm qhov dej ntws tseem ceeb yog 2.4% hauv Bivalirudin pawg sib piv nrog 4.1% hauv heparin ntxiv rau GPI pawg, 41% txheeb ze kev twv txiaj. Qhov kev sim ACUITY, uas tau tso npe ntau dua 13,000 cov neeg mob uas muaj mob plawv, kuj tau qhia tias Bivalirudin ib leeg tau cuam tshuam nrog kev txo qis los ntshav loj piv rau heparin ntxiv rau GPI (3.0% vs. 5.7%).
Qhov txo qis los ntshav nrog Bivalirudin piv rau heparin tau raug ntaus nqi rau ntau yam. Ua ntej, Bivalirudin qhov ncaj qha thiab tshwj xeeb inhibition ntawm thrombin ua rau muaj kev kwv yees ntau dua thiab zoo ib yam tshuaj tiv thaiv coagulant, uas tuaj yeem txo qhov kev pheej hmoo ntawm overdosing thiab ntau dhau los tiv thaiv coagulation. Qhov thib ob, Bivalirudin qhov luv luv ib nrab-lub neej tso cai rau kev thim rov qab sai ntawm nws cov nyhuv anticoagulant tom qab txiav tawm, uas tuaj yeem txo qhov kev pheej hmoo los ntshav. Thib peb, Bivalirudin tsis cuam tshuam nrog PF4 lossis ua rau HIT, uas tuaj yeem ua rau muaj kev pheej hmoo tseem ceeb rau ntshav los ntshav nrog kev kho heparin.
Txawm li cas los xij, nws yog ib qho tseem ceeb uas yuav tsum nco ntsoov tias cov ntshav kom zoo ntawm Bivalirudin tshaj heparin tau sib tw los ntawm qee qhov kev tshawb fawb tsis ntev los no. Qhov kev sim HEAT-PPCI suav nrog ntau dua 1,800 tus neeg mob uas tau txais thawj PCI rau ST-segment elevation myocardial infarction (STEMI), thiab tsis muaj qhov sib txawv tseem ceeb hauv kev los ntshav ntawm Bivalirudin thiab heparin (3.5 feem pua vim 3.1 feem pua). Qhov kev tshawb pom no qhia tau hais tias cov txiaj ntsig los ntshav ntawm Bivalirudin yuav tsis tshua muaj tshwm sim hauv kev teeb tsa thawj PCI rau STEMI, qhov twg kev siv GPI tsis tshua muaj ntau thiab kev pheej hmoo los ntshav yuav muaj feem cuam tshuam rau cov neeg mob thiab cov txheej txheem txheej txheem.
Tsis tas li ntawd, tus nqi viability ntawmBivalirudincontrasted nrog heparin tau koom nrog banter, muab qhov kev siv nyiaj ntau dua ntawm Bivalirudin. Qee qhov kev tshawb fawb tau qhia tias kev siv niaj hnub ntawm Bivalirudin yuav tsis raug lees paub los ntawm kev saib xyuas kev noj qab haus huv, tshwj xeeb tshaj yog cov neeg mob qis dua lossis cov uas tsis muaj keeb kwm ntawm HIT.
Hauv kev kho mob, kev txiav txim siab siv Bivalirudin lossis heparin yuav tsum ua raws li kev saib xyuas zoo ntawm tus neeg mob yam xwm txheej, xws li kev pheej hmoo los ntshav, muaj kev sib txuam, thiab cov ntsiab lus tshwj xeeb hauv kev kho mob. Hauv cov neeg mob uas muaj kev pheej hmoo los ntshav los yog keeb kwm ntawm HIT, Bivalirudin tuaj yeem muab lwm txoj kev nyab xeeb rau heparin. Txawm li cas los xij, hauv cov neeg mob uas muaj kev pheej hmoo tsawg lossis cov uas tau txais thawj PCI rau STEMI, cov txiaj ntsig los ntshav ntawm Bivalirudin yuav tsis txaus, thiab heparin yuav nyiam vim nws tus nqi qis dua.
Hauv cov ntsiab lus, thaum ntau qhov kev sim loj tau pom tias muaj kev pheej hmoo los ntshav nrog Bivalirudin piv rau heparin ntxiv rau GPI, qhov los ntshav zoo ntawm Bivalirudin yuav tsis tshua muaj tshwm sim hauv qee qhov chaw kho mob, xws li thawj PCI rau STEMI. Qhov kev txiav txim siab siv Bivalirudin lossis heparin yuav tsum yog tus kheej raws li tus neeg mob cov yam ntxwv thiab kev txiav txim siab hauv tsev kho mob, ntsuas qhov txiaj ntsig zoo thiab kev pheej hmoo ntawm txhua qhov kev xaiv.
Thaum twg Bivalirudin nyiam dua heparin hauv kev kho mob?
Hauv kev xyaum kho mob, kev xaiv ntawm Bivalirudin thiab heparin nyob ntawm ntau yam, xws li cov ntsiab lus kho mob tshwj xeeb, tus yam ntxwv ntawm tus neeg mob, thiab qhov sib npaug ntawm qhov txaus ntshai thiab txiaj ntsig rau txhua kis. Muaj ntau qhov xwm txheej uas Bivalirudin yuav nyiam dua heparin, raws li cov pov thawj tam sim no thiab cov lus qhia.
Cov neeg mob uas muaj keeb kwm ntawm heparin-induced thrombocytopenia (HIT) lossis muaj kev pheej hmoo siab rau kev tsim HIT yog ib qho ntawm Bivalirudin cov lus qhia tseem ceeb tshaj plaws. Kev kho mob heparin tuaj yeem ua rau HIT, ib qho teeb meem loj hauv kev tiv thaiv kab mob sib kis uas tuaj yeem ua rau muaj qhov tsis sib xws thiab thrombocytopenia. Hauv cov neeg mob uas muaj keeb kwm yav dhau los cim los ntawm HIT, rov qhib siab rau heparin tuaj yeem tso tawm qhov rov ua dua sai thiab hnyav ntawm cov lus teb muaj kev nyab xeeb, ua rau muaj teeb meem txaus ntshai.Bivalirudin, raws li cov thrombin inhibitor ncaj qha uas tsis cuam tshuam nrog platelet factor 4 (PF4), tsis ua rau HIT thiab tuaj yeem siv nyab xeeb los ua lwm yam tshuaj tiv thaiv coagulant hauv cov neeg mob no.
American School of Cardiology Tsim/American Heart Affiliation (ACCF/AHA) txoj cai rau kev tswj hwm ntawm ST-qhov siab myocardial tuag cov ntaub so ntswg (STEMI) qhia Bivalirudin raws li ib tug nyiam anticoagulant tshaj heparin nyob rau hauv cov neeg mob uas muaj keeb kwm yav dhau los cim los ntawm HIT los yog cov neeg uas muaj kev twv txiaj siab. rau HIT mus txog qhov tseem ceeb percutaneous coronary mediation (PCI). Bivalirudin kuj tau pom zoo los ua lwm txoj hauv kev rau heparin rau cov neeg mob HIT hauv kev tswj hwm tus mob coronary syndromes cov lus qhia los ntawm European Society of Cardiology (ESC).
Lwm qhov xwm txheej uas Bivalirudin yuav nyiam dua heparin yog nyob rau hauv cov neeg mob uas muaj kev pheej hmoo siab los ntshav. Raws li tau tham ua ntej, ntau qhov kev sim loj tau pom tias muaj kev pheej hmoo los ntshav loj nrog Bivalirudin piv rau heparin ntxiv rau glycoprotein IIb / IIIa inhibitor (GPI) hauv cov neeg mob hauv PCI. REPLACE-2 thiab ACUITY kev sim tau pom qhov txo qis hauv cov ntshav loj nrog Bivalirudin piv rau heparin ntxiv rau GPI, yam tsis muaj kev cuam tshuam cov txiaj ntsig ischemic.
ACCF / AHA cov lus qhia rau PCI pom zoo xav txog Bivalirudin ua lwm txoj hauv kev heparin hauv cov neeg mob uas muaj kev pheej hmoo siab los ntshav, xws li cov hnub nyoog siab, poj niam txiv neej, lub cev tsis muaj zog, lossis lub raum tsis ua haujlwm. ESC cov lus qhia rau kev tswj cov mob plawv mob plawv kuj qhia tias Bivalirudin yuav raug txiav txim siab hauv cov neeg mob uas muaj kev pheej hmoo siab los ntshav los ntawm PCI.
Hauv kev teeb tsa ntawm kev phais plawv, Bivalirudin yuav nyiam dua heparin hauv cov neeg mob uas muaj keeb kwm ntawm HIT lossis cov neeg muaj kev pheej hmoo siab los ntshav. Ntau qhov kev tshawb fawb tau qhia txog kev ua tau zoo thiab kev nyab xeeb ntawm Bivalirudin ua lwm txoj hauv kev rau heparin hauv cov neeg mob uas tau txais kev kho mob ntawm cov hlab ntsha ntawm lub plawv (CABG) los yog kev phais valve. Kev sim EVOLUTION-ON, uas piv Bivalirudin rau heparin nrog protamine reversal nyob rau hauv cov neeg mob CABG, pom tiasBivalirudintau cuam tshuam nrog txo qis 24-teev lub hauv siab lub raj dej thiab cov kev xav tau hloov pauv piv rau heparin.
Txawm li cas los xij, nws yog ib qho tseem ceeb uas yuav tsum nco ntsoov tias niaj hnub siv Bivalirudin hauv kev phais plawv tseem muaj teeb meem, muab nws cov nqi siab dua thiab tsis muaj pov thawj tseeb rau kev ua tau zoo tshaj heparin nyob rau hauv cov nqe lus ntawm kev kho mob. Qhov kev txiav txim siab siv Bivalirudin hauv kev phais plawv yuav tsum yog tus kheej raws li tus neeg mob yam xwm txheej thiab cov txheej txheem hauv tsev, ntsuas cov txiaj ntsig thiab cov nqi.
Ntxiv nrog rau cov lus qhia tshwj xeeb no, tej zaum yuav muaj lwm qhov xwm txheej kho mob uas Bivalirudin nyiam dua heparin raws li tus neeg mob yam xwm txheej thiab kev txiav txim siab kho mob. Piv txwv li, nyob rau hauv cov neeg mob uas muaj keeb kwm ntawm kev tsis haum tshuaj rau heparin lossis cov neeg uas muaj thrombocytopenia hnyav los ntawm lwm yam ua rau, Bivalirudin yuav yog ib qho kev nyab xeeb rau kev tiv thaiv coagulation.
Hauv cov ntsiab lus, Bivalirudin nyiam dua heparin hauv ntau qhov chaw kho mob, suav nrog cov neeg mob uas muaj keeb kwm ntawm HIT, cov neeg muaj kev pheej hmoo siab los ntshav, thiab qee cov neeg mob uas tau txais PCI lossis kev phais plawv. Qhov kev txiav txim siab siv Bivalirudin yuav tsum yog ua raws li kev saib xyuas kom zoo ntawm tus neeg mob yam tseem ceeb, ntsuas qhov txiaj ntsig zoo thiab kev pheej hmoo ntawm txhua qhov kev xaiv anticoagulant. Raws li cov pov thawj kho mob txuas ntxiv mus, nws yog ib qho tseem ceeb rau cov kws kho mob kom nyob twj ywm tshiab ntawm cov lus qhia tshiab thiab cov lus pom zoo rau kev siv Bivalirudin thiab heparin hauv ntau qhov chaw kho mob.
Cov ntaub ntawv
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