ACCFACGAHA专家共识更新

ACCF/ACG/AHA专家共识更新作者：河北省人民医院郭艺芳整理来源：中国医学论坛报为减少抗血小板药物对胃肠道的不良影响，美国心脏病学会基金会（ACCF）、美国胃肠病学会（ACG）及美国心脏学会（AHA）于2008年联合发表专家共识，建议接受抗血小板或（和）非类固醇类抗炎药（NSAID)治疗的患者积极应用质子泵抑制剂（PPI）。

然而2009年初所公布的一项大型病例对照研究却显示，联合应用氯吡格雷与PPI可能会增加心血管不良事件的发生。

此研究一度引起广泛关注，但随后陆续发表的一系列研究所得的结论却存在分歧，令临床医师无所适从。

2010年11月8日，ACCF/ACG/AHA对相关文献进行总结与分析后，更新了2008年版的专家共识。

虽然关于PPI是否会影响氯吡格雷的抗血小板作用尚无最终定论，但更新的指南仍根据现有证据为临床医师的临床实践提供了建议，这无疑是一个进步。

新版《共识》要点对于降低抗血小板治疗和应用NSAID的胃肠道风险，更新的《ACCF/ACG/AHA降低抗血小板治疗和应用NSAID的胃肠道风险专家共识》（简称《共识》）主要有以下11点要点。

1. 氯吡格雷是预防动脉粥样硬化性心血管病患者血栓事件的有效药物。

2. 与单独使用阿司匹林相比，联合应用氯吡格雷与阿司匹林可进一步降低冠心病患者以及支架置入术后患者的血栓形成事件风险。

3. 氯吡格雷与阿司匹林单独或联合应用可增加胃肠道出血风险。

4. 胃肠道出血的高危人群包括：曾有胃肠道出血史，高龄，同时接受抗凝剂、类固醇类抗炎药或NSAID（包括阿司匹林）治疗，以及幽门螺杆菌感染者。

存在上述多种危险因素者的胃肠道出血危险可进一步增高。

5. 与单用抗血小板药物相比，加用PPI或组胺2（H2）受体拮抗剂可降低上消化道出血危险，而PPI的疗效优于H2受体拮抗剂。

6. 对于需要接受抗血小板治疗的患者，建议对曾有胃肠道出血史者预防性应用PPI，对于存在多种其他出血高危因素者，也可考虑应用PPI预防胃肠道出血。

是胃食管反流病不是“冠心病”发表时间：2008-11-20发表者：申海涛(访问人次：913)一般资料：石X X，男，53岁，某旅游巴士有限公司员工。

因“胸背痛、胸闷、憋气8年，加重7个月”于2008-01-09入我院。

患者在8年前无明显诱因出现胸背痛。

发作时胸痛主要表现为胸骨后明显，为闷痛。

向后背部放散，伴有胸闷、出汗、休息及活动后均可以发作。

每次发作持续数十分钟至数小时。

含服硝酸甘油效果不理想。

无反酸、无反胃，无明显烧心症状。

因胸背痛发作多次就诊于北大医院急诊科，心电图无明显动态改变，心肌酶谱及胸片均无异常，服用异舒吉（异舒吉作用与硝酸甘油相似，但较持久，能维持4小时以上)，症状可以稍缓解，但是仍旧反复发作。

于2007年5月因再次发作就诊于解放军第305医院，诊断“冠心病”。

并行冠脉造影结果显示前降支30-40%狭窄，回旋支30-40%狭窄，右冠95%狭窄。

遂行右冠脉植入支架1枚。

术后坚持服用阿斯匹林、波立维、消心痛。

但是症状较前无明显改善，仍反复发作胸痛、胸憋。

患者平素有腹胀、偶有嗳气、咽部不适感。

为进一步诊治。

遂在305医院行食管压力测定结果LESP正常，食管体部静息压正常，LES功能完整。

食管24小时测酸结果为轻度酸反流，DeMeester评分40.35。

胃镜结果为慢性浅表性胃炎。

心脏超声显示左室舒张功能减低。

动态心电图显示1.窦性心率，2.偶发房早。

胸部CT检查：未见明显异常。

遂给予雷贝拉唑、硫糖铝、加斯清等药后胸骨后疼痛、胸憋症状有缓解。

为进一步诊治。

到我院就诊。

以“胃食管反流病”收入我院。

患者既往高血压病史7年，最高达180/110mmHg，近年规律服用“比索洛尔、洛活喜”。

发现空腹血糖异常8个月，最高达8.2mmol/L，未明确诊断糖尿病。

入院后按胃食管反流病给予药物诊断性试验治疗一周（埃索美拉唑20mg 2/日口服、铝碳酸镁片1g 3/日，多潘立酮片 10mg 3/日口服）。

胸背痛有明显缓解，原来一直存在的咽部不适症状改善最明显。

应用NSAID胃肠道风险及降低抗血小板治疗的专家共识2011-1越来越多的证据证实抗血小板药物在预防动脉粥样硬化血栓事件中的获益，抗血小板药物的应用不断增加。

然而应用抗血小板药物确实存在风险，尤其是胃肠道并发症，例如消化性溃疡及与之相关的消化道出血。

这些风险在抗血小板药物联合应用，及与其他的药物如非甾体类抗炎药(NSAID)、糖皮质激素及抗凝药合用时会进一步增加。

基于临床上抗血小板治疗的广泛性，医生有必要了解抗血小板治疗在预防心脑血管事件发生中的获益以及相关的风险。

只有了解了这些，临床医生才能合理充分的评估每个患者的风险与获益，给予最佳的治疗方案。

2008年发布的美国心脏病学院基金会/美国胃肠病学会/美国心脏协会(ACCF/ACG/AHA)降低抗血小板治疗及应用NSAID胃肠道风险的专家共识对于抗血小板药物应用给出了与以往不同的建议。

(CircuLation，2008，118:1894—190%)1阿司匹林和其他NSAID的胃肠道并发症建议:当服用任何NSAID时，包括COX-2选择性药物和非处方剂量的传统NSAID以及心脏病治疗剂量的阿司匹林，都会增加溃疡并发症的风险，对于具有溃疡风险的患者应同时处方胃肠道保护药物。

上消化道事件包括有症状的以及并发的溃疡，在NSAID服用者中每20例有1例发生，每7例老年人有1例发生，占上消化道事件相关的住院和死亡的30%消化不良定义为上腹痛或上腹部不适，可发生于服用NSAID包括阿司匹林的患者。

消化不良不能准确的提示溃疡的存在，因为它的发生太常见了。

NSAID还会加重一些胃食管反流病患者的症状。

每年NSAID相关的上消化道事件的发生率为2.O%,4.5%，出血、穿孔、梗阻的风险为0.2,1.9%。

每年因NSAID导致的住院为10,20/1000，死亡率增加4倍。

仅在美国，关节炎患者中每年因服用NSAID导致10700次住院和16500例死亡。

联合应用阿司匹林和其他NSAID的人群是另一组高危人群。

2021版：ACC 优化心衰治疗的决策路径专家共识更新版（最全版）1 引言心衰的患病率正迅速升高（5）。

除此之外，心衰是一种消耗大量医疗资源的疾病，造成相当大的发病率和死亡率，并严重影响患者的生活质量。

重要的突破包括广泛的药物治疗、设备和管理策略，重新定义了改变疾病自然史的机会。

本次ECDP重点更新，目的是用新兴研究的数据补充2017年的ECDP，并继续为HFrEF患者的管理提供简洁实用的指导。

保留了2017 ECDP中10个关键问题的格式，并更新了其相关的治疗方案和表格以适应这一不断发展的新证据。

HFrEF中的十个关键问题1.如何开始、添加或转换为新的循证指南导向的HFrEF治疗；2.如何实现心衰患者的最佳治疗，包括使用改变指南推荐方案的多种药物及强化临床评估（例如，影像学数据、生物标志物和充盈压）；3.何时将患者转诊至心衰专家；4.如何应对管理协调方面的挑战；5.如何提高用药依从性；6.特定的患者队列（非裔美国人、老年人和体弱者）的需求；7.如何管理患者的费用和改善心衰药物的可及性；8.如何管理日益复杂的心衰；9.如何管理常见共病；10.如何整合姑息治疗和过渡至临终关怀。

2 方法最初的2017年ACC ECDP采用结构化格式起草，该格式是2016年和2017年ACC/AHA/心衰SA对2013年ACCF/AHA 心衰指南重点更新发布之后创建的（2,4,6）。

ECDP的演进涉及提出问题，以发现证据差距，并召集一个多学科的参与方小组，他们对文献进行综述以汇总涉及当代心衰治疗的相关证据。

当时，ECDP主席和副主席分别对参考文献进行了审查，并制定了议定的纲要。

在2016年7月19日于ACC心脏之家举行的现场圆桌会议之前，已向小组的每个成员提供了参考文献的印刷本。

心衰圆桌会议的参与者包括心脏病专家、内科医师、急诊医师、住院医师、护士、患者权益团体代表、药剂师、培训研究员、质量改进专家、流行病学家和生物统计学家。

#述评#氯吡格雷与质子泵抑制剂朱国英*关键词氯吡格雷;质子泵抑制剂;胃肠道出血今年初陆续发表于5加拿大医学会杂志6和5美国医学会杂志6的两项大规模回顾性研究显示,氯吡格雷与质子泵抑制剂(PPI)联用增加心血管事件发生风险。

/一石激起千层浪0,引起了心血管医生和消化科医生的极大关注,围绕抗血小板治疗引发了更多的思考,也还有待问题的澄清。

1抗血小板治疗与消化道出血越来越多的证据证实抗血小板治疗在预防动脉粥样硬化血栓事件中获益,使抗血小板药物的应用不断增加。

2007年和2008年欧洲心脏病学会(ESC)和美国心脏病学会/美国心脏协会(ACC/AHA)发布的/非ST段抬高急性冠状动脉(冠脉)综合征(NSTE-ACS)0和/ST段抬高急性冠脉综合征(STE-ACS)0以及/冠脉介入治疗(PC I)0指南中都强调了抗血小板治疗的重要性,推荐:/所有患者0、/尽早应用0、/双联药物(阿司匹林+氯吡格雷)0、/氯吡格雷负荷量+维持量0和/长期应用0等抗血小板治疗建议。

全球有近10万名ACS患者参与了氯吡格雷的各种大型随机化、双盲对照研究,充分验证了氯吡格雷的疗效和安全性。

在阿司匹林基础上加用氯吡格雷的双联抗血小板治疗得到了包括ESC,ACC/AHA和美国胸科医师学会(ACCP)在内的众多国际权威指南推荐。

然而,随着抗血小板治疗的人群基数加大、从一级预防到二级预防以及用药时间之长(通常为数十年),在减少心血管事件的同时却增加了胃肠道并发症包括消化性溃疡及与之相关的消化道大出血发生率(0119j~ 116j),这些风险在抗血小板药物的联合用药以及与其他药物如非甾体类抗炎药(NSA I D)、糖皮质激素及抗凝药物合用时会进一步增加。

因此,抗血小板治疗出血风险不容忽视,医生必须合理评估每个患者的风险与获益,给予最佳的治疗方案。

为此,2008年10月由美国心脏病学会基金会/美国胃肠病学会/美国心脏协会(ACCF/ ACG/AHA)共同发布的/降低抗血小板治疗及应用NSA I D的胃肠道风险的临床专家共识0,对于抗血小板药物应用建议如下:由于NSA I D与抗血小板制剂(如阿司匹林)可以增加患者溃疡性胃肠道合并症的危险,故对于胃肠道出血高危患者应给予必要的胃肠道保护性治疗。

解读美国心脏病学院和美国心脏协会最新心力衰竭治疗指南美国心脏病学院基金会（ACCF）和美国心脏协会（AHA）新近联合发表了心力衰竭（简称心衰）患者治疗临床实用指南[1]。

为了帮助临床医师选择具体患者的最佳治疗策略，新指南对心衰的定义和分类进行了修订，重点强调以患者为中心的结果，例如生活质量、参与决策、护理协调、过渡和姑息治疗。

一、新版指南的主要内容1.心衰的分类与定义分为2类4期。

第1类：左室射血分数（LVEF）减低（≤40％）的心衰（HFrEF），也称为收缩期心衰。

第2类：LVEF保留（≥50％）的心衰（HFpEF），也称为舒张期心衰，又分为LVEF临界（41-49％）和LVEF 改善（＞40％）两种。

A期：心衰高危但无结构性心脏病或心衰症状。

B 期：有结构性心脏病但无心衰体征或症状。

C期：有结构性心脏病且（曾）有心衰症状。

D期：顽固性心衰且需要特殊干预。

ACC和AHA的这种分期强调疾病的发生与进展，用于描述具体的患者和人群。

纽约心脏协会（NYHA）的分级则强调运动能力和疾病的症状状态。

2.心衰（包括HFpEF）患者的初次和多次评估病史和物理检查应认真询问病史并进行全面的物理检查，寻找导致心衰发生或加速进展的心性和非心性疾患或行为。

在特发性扩张型心肌病（DCM）患者，询问3代家族史，帮助诊断家族性DCM。

在患者每次就诊时评估其容量状态和生命体征，包括多次评估体重、颈静脉压和有否外周水肿或端坐呼吸。

风险评分多变量风险评分可评估门诊或住院患者发生死亡的风险。

应用风险评分预测慢性患者结果的模型包括西雅图心衰模型、心衰存活评分、CHARM风险评分和CORONA风险评分。

I-PRESERVE评分尤其适合于慢性HFpEF。

在急性失代偿性患者，应用ADHERE分类回归树状模型、AHA随指南而行评分、EFFECT风险评分、ESCAPE风险模型和出院评分、以及优化心衰风险预测列线图。

诊断性检查初次化验检查包括全血细胞计数、尿液分析、血清电解质（包括钙与镁）、血尿素氮、血清肌酐、血糖、空腹血脂、肝功能和甲状腺刺激素。

质子泵抑制剂的合理使用目前质子泵抑制剂包括奥美拉唑、兰索拉唑、泮托拉唑、雷贝拉唑、埃索美拉唑等药物。

这些药物可使正常人及溃疡患者的基础胃酸分泌及由组胺、胃泌素等刺激引起的胃酸分泌明显受到抑制;还可对胃黏膜有保护作用,尤其对阿司匹林、乙醇、应激所致的胃黏膜损伤有保护作用;也可增强抗菌药如阿莫西林、克拉霉素、甲硝唑、四环素、呋喃唑酮等对幽门螺杆菌的根除率(可能与通过抑制细菌ATP酶活性而抑制细菌生长有关),故常用于十二指肠溃疡、胃溃疡、反流性食管炎和卓-艾综合征(胃泌素瘤)等病,是治疗消化性溃疡病的良药。

质子泵抑制剂对十二指肠溃疡、胃溃疡的剂量为每日20 mg,每日1~2次。

对十二指肠溃疡2~4周为一疗程;胃溃疡愈合一般为4~6周,病情严重时,4~8周为一疗程,即可有效缓解溃疡症状,亦可促进溃疡愈合,但多和抗菌药联合应用,使用抗菌药根除幽门螺杆菌也是治疗该病或防止复发的关键措施。

尽管溃疡病属慢性病,但一般经过4~8周的持续治疗后,大多数溃疡可愈合,病情痊愈,因此该药的疗程应尽可能控制在8周之内。

为了防止消化道溃疡病的复发,此后医生还会要求患者继续服用小剂量抗溃疡药,以巩固疗效。

对此,应小剂量服用H2受体阻断剂,该类药物不良反应小;还可选用增强胃黏膜屏障作用的药物,如米索前列醇、恩前列素、硫糖铝、麦滋林S、替普瑞酮、蒙脱石等,这些药物有促进黏液和碳酸氢盐分泌;促进胃黏膜受损上皮细胞的重建和增殖,增强细胞屏障;或在溃疡面形成保护屏障;或促进黏膜合成前列腺素,增加血流量,刺激黏膜细胞再生,增强胃黏膜屏障能力;或杀灭幽门螺杆菌等。

应用这类药物可有效降低溃疡病的再复发,但不宜选用抑酸作用强及不良反应较多的质子泵抑制剂长期治疗和预防消化道溃疡。

质子泵抑制剂作用强而持久,每日口服奥美拉唑200 mg,连续7天,基础胃酸p H值可从1.4升至5.3;一次服用40 mg,3天后,胃酸分泌部分受到限制。

所以,在质子泵抑制剂应用期间不宜长期或大剂量与抗酸药及胃酸抑制剂联用,如抗酸药碳酸氢钠片、鼠李铋镁片、三硅酸镁、铝碳酸镁等;胃酸抑制药如H2受体阻断剂西咪替丁、法莫替丁、雷尼替丁等;胆碱受体阻断剂如阿托品、哌仑西平等,以免胃酸被过度抑制,引起其他疾病。

2011年ACCF/AHA不稳定型心绞痛/非ST段抬高心肌梗死治疗指南（2007年指南的焦点更新）J Am Coll Cardiol, doi:10.1016/j.jacc.2011.02.009 (Published online 28 March 2011)/cgi/content/full/j.jacc.2011.02.009v13. 早期院内治疗3.2 可能或者确定诊断为UA/NSTEMI病人的抗血小板/抗凝治疗的推荐3.2.1 抗血小板治疗的推荐（表2）3.2.3抗血小板和抗凝之外的治疗推荐表3 抗血小板和抗凝之外的治疗推荐3.3.起初保守治疗还是起初侵入性治疗策略（参见表4）表4 最初侵入性治疗策略与保守性治疗策略的推荐5.住院后期护理，出院和出院后护理5.2. 长期的药物治疗和二级预防5.2.1. 抗血小板治疗的推荐（表5）表 5 抗血小板治疗推荐5.2.6. 华法令抗凝治疗的推荐6.5 慢性肾脏疾病（CKD）推荐在使用造影剂之前的至少12小时内进行水化，以达到扩容的目的，并同时抑制肾素系统。

造影剂使用完毕后水化要持续12-20小时（Nephrol Dial Transplant 1999;14:1064-1066.）。

水化的基本原则是单独使用等张或者半浓度的生理盐水（0.45%），这是传统的金标准。

最近，正在试验使用碳酸氢钠作为水化溶液。

一些研究认为在预防造影剂诱发的肾病（CIN）上碳酸氢钠优于生理盐水。

最新的研究显示造影剂体积与肌酐清除率的比值>3.7是血清肌酐浓度异常升高的显著性的、独立的预测因子。

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