血小板聚集是由于其表面GpIIb/IIIa 受体偶联相关，因此出现了特异性GpIIb/IIIa受体拮抗剂替罗非班。但GpIIb/IIIa受体 偶联也受P2Y12受体影响。波立维通过选择性抑制二磷酸腺苷（ADP）与血小板P2Y12受体受体结合，从而阻断ADP介导的糖蛋白GPⅡb/Ⅲa复合物的活化，减少血小板之间的相互粘附，降低血栓形成的风险。
比波立维更早的药物噻吩吡啶存在时间很短即被淘汰，目前均为二代噻吩吡啶类药物，包括氯吡格雷，普拉格雷，三者均需进过肝内酶代谢后产生生物活性。而非噻吩吡啶类药物坎格雷洛，为无活性前体药，可静脉直接使用，因此常用于ACS行PCI患者。替格瑞洛另一种非噻吩吡啶药物，入体内后仍需肝脏转换，为口服制剂。几种药物特点见下图：
美国胸科医师协会（ACCP）2023年更新了围手术期抗血小板指南，并给出一张简洁明了的图，详细指南如下：
（1）小手术例如皮肤科，眼科，牙科等小手术，如仅服用ASA 或P2Y12抑制剂，可不停用，如合用ASA和P2Y12，可停用其中任何一种。
（2）In patients receiving ASA who are undergoing elective non-cardiac surgery, wesuggest ASA continuationover ASA interruption. In patients receiving ASA therapy who are undergoing elective surgery and require ASA interruption, we suggeststopping ASA ＜7 daysinstead of 7 to 10 days before the surgery. In patients receiving clopidogrel who are undergoing an elective non-cardiac surgery, we suggeststopping clopidogrel 5 daysinstead of 7 to 10 days before the surgery,stopping ticagrelor 3 to 5 daysinstead of 7 to 10 days before the surgery,stopping prasugrel 7 daysinstead of 7 to 10 days before the surgery.In patients who require antiplatelet drug interruptionwe suggest to resume antiplatelet drugs ＜24 hoursinstead of > 24 hours after the surgery/procedure.不建议在术前停用阿司匹林（颅内手术，脊柱手术除外），如必须停用，可停用＜7天，如服用波立维，只需停用五天，替卡格雷只需停用3-5天，普拉格雷停用7天，并在手术结束后24小时即可恢复使用）
（3）围手术期没必要监测血小板功能
（4）In patients receiving ASA and a P2Y12 inhibitor with coronary stents placed within the last 6 to 12 weeks who are undergoing an elective surgery, we suggest either continuation of both antiplatelet agents or stopping one antiplatelet agent within 7 to 10 days of surgery. within the last 3 to 12 months and are undergoing an elective surgery, we suggest stopping the P2Y12 inhibitor prior to surgery over continuation of the P2Y12 inhibitor。冠脉支架植入后6-12周患者服用双抗，建议停用其中一种药物7-10天，也可不必停药。冠脉支架植入后3-12月，建议停用P2Y12抑制剂
（5）In patients with coronary stents who require continued dual antiplatelet therapy, we suggest delaying an elective surgery/procedure over not delaying the surgery/procedure. In patients with coronary stents who require interruption of antiplatelet drugs for an elective surgery, we suggest against routine bridging therapy with a glycoprotein IIb/IIIa inhibitor, cangrelor, or LMWH over routine use of bridging therapy（择期手术患者不能停用双抗者，建议延期手术。如必须手术，不建议使用IIb/IIIa受体拮抗剂，低分子肝素等桥接，而使用常规肝素桥接）
Anesthesiology最新一期综述概括了上述所有ADP抑制剂的作用特点以及围手术期出血如何处理，全文链接点击阅读原文。
热门跟贴