Acute coronary syndrome ACS is combined with the diagnosis and treatment of gastrointestinal bleeding

As the cornerstone of acute coronary syndrome (ACS) drug therapy, double antiplate plate plate therapy can significantly reduce the incidence of early and long-term adverse cardiovascular events for ACS and its patients receiving interventional therapy.
, however, the various bleeding complications associated with anti-embolism treatment are also increasing.
about ACS bleeding complications, digestive tract bleeding not only has a higher incidence, but also seriously affects the patient's prognosis, which deserves special attention! When ACS "experiences" "upper gastrointestinal bleeding", what strategies should clinically be adopted? Epidemiological GRACE, HORIZONS-AMI, ACUITY, and ACUITY studies showing that the risk of 30 d hemorrhage in ACS patients in hospitals is as high as 3.0%-8.3 Meanwhile, a 2014 study published in the Chinese Journal of Cardiovascular Research showed a 6.4% incidence of severe bleeding (BARC type ≥3) in STEMI patients with emergency PCI.
, the proportion of related bleeding in non-puncture sites was higher than that of bleeding at puncture sites, and it was mainly in the digestive tract.
NCDR Cath PCI registration study showed that in patients with PCI postoperative bleeding accounted for 57.9%, gastrointestinal bleeding was 16.6%, and a Swiss PCI registered study showed that PCI patients 1 year antiplate plate plate treatment during different parts of the bleeding, the proportion of gastrointestinal bleeding is about 30%, the highest proportion.
can significantly increase the short-term and long-term mortality of ACS patients, and for ACS patients, active prevention of gastrointestinal bleeding is particularly important.
analysis based on the ACUITY study shows that gastrointestinal bleeding is an independent predictor of death in ACS patients for 30 days and 1 year, and is prone to worsening clinical outcomes in patients.
the mechanism by which ACS combines gastrointestinal bleeding is most common in bleeding caused by anti-thrombotic drugs.
Anti-thrombosis drugs, including antiplate plateboard drugs and anticoagulant drugs, lead to the mechanism of gastrointestinal bleeding is more complex, often can be divided into four conditions.b aspirin through local and systemic action caused by the digestive tract mucosa damage, bleeding.b the end-of-life pathway of plateplate aggregation is blocked by the GPI, which causes bleeding by strong inhibition of plateplate aggregation, and bleeding caused by new anticoagulant drugs (Dabiga group, devasaban, apixaban, etc.) is often associated with excessive dose of the drug, the patient's old age, heart failure, and a history of gastrointestinal bleeding.
Characteristics of digestive tract damage caused by aspirin: 12 months after taking the drug for the multiple stages of digestive tract damage, 3 months peak;
Aspirin high-dose, low-dose can increase the risk of upper gastrointestinal ulcer bleeding; elderly patients are high-risk groups of antiplate plateboard drug digestive tract damage, the older the risk, the greater the risk; Helicobacter pyridobacteria (HP) infection can aggravate the role of aspirin's digestive tract damage, before the start of long-term antiplate plate plate treatment, it is recommended that there is Patients with the condition should detect and eradicate HP; aspirin in association with other antiplate plate plates or anticoagulants significantly increases the risk of severe bleeding, mainly in the digestive tract bleeding; aspirin dosage form improvement can not avoid the risk of digestive tract damage, the difference between different dosage forms of aspirin peptic ulcers and the risk of gastrointestinal bleeding is not statistically significant.
"systemic action" on aspirin to the digestive tract damage contribution is greater, for aspirin intestinal solution tablets, local direct stimulation effect is reduced, but COX-2 cyclooxidase activity inhibition of the systemic effect still exists.
(Figure 1) Figure 1. Aspirin's mechanism for digestive tract damage, ACS, combined with risk assessment of gastrointestinal bleeding and prevention of PCI preoperative use of CRUSADE scores to predict bleeding risk in ACS patients.
CRUSADE score includes 8 indicators of hospitalization: baseline blood cell ratio, creatinine removal rate, heart rate, systolic blood pressure, sex (female), signs of congestive heart failure in symptoms, past history of vascular disease or stroke, diabetes.
according to the CRUSADE score, patients can be divided into five levels: very low risk ≤20 points;
"ACS anti-thrombosis treatment combined bleeding prevention multidisciplinary expert consensus 2016" recommended, ACS patients on the gastrointestinal bleeding prevention strategies include: 1. reasonable selection and use of anti-thrombotic drugs; 2. the use of oral anticoagulants to reduce coagulants; 3. special ACS patients anticoagulant therapy; 4. the application of proton pump inhibitors (PPI) to prevent gastrointestinal bleeding.
antiplates should I choose? 1) Aspirin: long-term use of suitable choice of intestinal soluble preparations; 2) P2Y12 inhibitors: if the risk of bleeding is not high (e.g. CRUSADE ≤30 points), NSTE-ACS patients, direct PCI STEMI patients, it is recommended to choose a priority for Teglilo.
results from the PLATO study showed that the treatment of tigrillo double resistance for one year significantly reduced the risk of major cardiovascular events in patients without increasing the risk of major bleeding compared to clopidogrel.
a 2016 study published in the Journal of Clinical Military Medicine showed that for ACS patients with drug-free stent implants, tigrillo significantly reduced the risk of cardiovascular events and death for one year compared to clopidogrel without increasing the risk of fatal haemorrhage.
non-oral anticoagulant drugs should be selected? 1) For patients with NSTE-ACS, if the risk of bleeding is high (e.g. CRUSADE ≥31 points), PCI preoperatively recommended the use of sulfonda hepatic pyridina≥ (2.5 mg subsurfic injection, 1 time/d); For patients with proposed PCI, if there is a high risk of bleeding (e.g. CRUSADE≥41 points), PCI is also recommended to use bivaldestin, but after surgery does not emphasize high dose maintenance application≤
the principle of joint use of anti-thrombotic drugs? 1) The use of GPI in conventional upstream (e.g. ambulances and emergency rooms) increases the risk of bleeding and should not be recommended; 2) patients with high risk (e.g. serum tachybocalin positive), globular indicates that patients with heavy thrombosis load or who have not given adequate load P2Y12 vector inhibitors may consider using GPI intravenously.
If GPI is required, the dose of UFH used in PCI surgery should be adjusted to 50-70 u/kg;
ACUITY study showed that conventional upstream GPI therapy significantly increased the risk of bleeding in patients with medium to high risk ACS, and synergy studies showed a significant increase in the risk of bleeding in patients with PCI perioperative cross-use of UFH and LMWH.
Special ACS patient anti-thrombosis treatment: 1. Long-term use of oral anticoagulant (OAC) patients: long-term use of OAC is a relatively taboo of thrombosis treatment; Anti-drugs; after surgery recommended triple anti-thrombosis treatment 4-6 W changed to double anti-thrombosis (P2Y12 subject inhibitor and OAC), recommended the use of a new oral anticoagulant (NOAC);
THE MULTIdisciplinary Expert Consensus 2016 recommends that for those at higher risk of gastrointestinal bleeding, such as combined gastrointestinal ulcers or a history of haemorrhage; long-term use of nonsteroidal anti-inflammatory drugs (NASIDs) or ponisson; Two or more risk factors: age ≥65 years old; indigestion; gastroesoesoesia reflow disease; HP infection; long-term alcohol consumption, recommended on a DAPT basis with PPI (3-6 months), after 6 months may be considered to continue or intermittently take to prevent or reduce gastrointestinal bleeding.
"ACS anti-thrombosis therapy combined hemorrhage prevention multidisciplinary expert consensus 2016" ( 10 ) stressed that: part of the PPI through CYP2C19 competition to inhibit the antiplatelet effect of clopidogrel, for patients taking clopidogrel, it is still recommended to choose as much as possible, such as lutonazole, reberazole and other less significant drugs.
ADAPT-DES study showed that clopidogrel and PPI were associated to reduce plate suppression and increase the risk of cardiovascular events, while PLATO subgroup analysis showed that the association of tegrelo and PPI did not affect its clinical efficacy in reducing cardiovascular events and did not increase major bleeding.
ACS anti-thrombosis treatment combined with gastrointestinal bleeding treatment for ACS anti-thrombosis treatment combined bleeding patients, should complete the double assessment of bleeding and isoemia as soon as possible, in the selection of reasonable hemorrhage regimen (oppressive hemorrhage, drug therapy, endoscopic treatment, surgery, etc.), on the basis of the decision of follow-up anti-thrombosis treatment strategy.
Cardiovascular physicians should integrate multidisciplinary advice to make the best clinical decisions during the assessment and treatment of bleeding, the assessment of isoemia risk, and the adjustment of anti-thrombosis strategies.
Figure 2. ACS patients anti-thrombosis treatment combined bleeding clinical decision path ACS patients in the course of anti-thrombosis treatment once the upper digestive tract bleeding, should first assess whether the hemodynamics is stable, whether it is necessary to take blood transfusion and vascular active drug use;
patients with minor bleeding (e.g. BARC hemorrhagic type 3) may continue to take anti-thrombotic drugs with adequate hemorrhage and monitoring, and patients with severe bleeding (e.g. BARC hemorrhagic type ≥3) should consider the type and dosage of the drug.
When bleeding is uncontested or potentially life-threatening, medication should be stopped immediately and treated with neoplate plate infusions, and co-PPI therapy should be actively used in patients at high risk of thrombosis (e.g. BMS in ≤1 month or DES in ≤3 months), and DAPT should be retained as far as possible;
It is important to note that the use of antiplate plateplot drugs can be resumed after 5 d when the following conditions are considered to be under control: 1. Hemolytic stability; 2. Hemoglobin stabilization without blood transfusion; 3. hemouric nitrogen (BUN) does not continue to rise; 4. intestinal chirping is inactive; 5. hemorrhoid transfusion (non-essential conditions)
clinical practice, "re-bleeding" itself can also lead to an increase in the death rate.
endoscopy is an important method of ACS anti-embolism therapy combined bleeding treatment, endoscopic hemorrhage after "re-bleeding" predictive factors include hemodynamic instability, endoscopic active bleeding, ulcers greater than 2 cm, ulcers located in the upper part of the stomach or the back of the hemoglobin 100 g/L and the need for blood transfusion.
the summary of ACS is not puncture site bleeding, with the highest incidence of gastrointestinal bleeding, gastrointestinal bleeding can significantly increase the risk of death in ACS patients, reasonable assessment and identification of high-risk groups of gastrointestinal bleeding is essential.
In addition, in clinical practice, strategies should be actively adopted to prevent bleeding in the upper digestive tract of ACS patients, if the prevention is not good, once the upper digestive tract bleeding, first of all, we need to assess whether the hemodynamics is stable, at the same time should comprehensively assess the risk of isoemia and bleeding, adjust anti-thrombosis treatment strategy.
need to stop bleeding, often first consider venous PPI and other drugs, endoscopy, intervention to stop bleeding, but if still can not stop the bleeding can consider surgery.
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