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急性冠脉综合征后抗血栓治疗的管理
Management of Antithrombotic Therapy after Acute Coronary Syndromes


Fatima Rodriguez ... 心脑血管疾病 • 2021.02.04
相关阅读
• 直接PCI中基因型指导的口服P2Y12抑制剂选择策略 • 替格瑞洛或普拉格雷治疗急性冠状动脉综合征患者

随着有关新疗法的多项临床试验发表结果,临床指南迅速做出更改,因此急性冠脉综合征患者的抗血栓药物管理变得越来越复杂。患者和临床医师必须在权衡获益和风险的基础上做出临床决策,获益包括抗血小板药的抗血栓作用和抗凝剂的抗缺血作用,风险为包括严重、危及生命出血在内的出血风险。治疗决策应做到个体化,应在风险-获益评估中考虑到其他因素,包括但不限于患者的人口统计学特征、检查结果、实验室检查和影像学检查,以及患者的价值观和偏好。

急性冠脉综合征的病理生物学特征是冠状动脉粥样硬化斑块因裂隙、糜烂或破裂而断裂,进而导致血小板和凝血系统激活;其临床后果是心肌缺血或梗死(取决于冠状动脉阻塞的程度)1,2。我们最初根据12导联心电图(ECG)结果对急性冠脉综合征进行分类,将患者分到两个治疗路径:ST段抬高型(STE)患者的治疗路径和无持续性STE的患者的治疗路径。最初由ECG指导的风险分层决定了患者住院期间的大多数治疗决策,并且对预后和出院后的治疗建议也很重要。

据估计,美国每年有72万人因急性冠脉综合征住院或发生致死性冠心病3。高龄和合并症是急性冠脉综合征患者的典型特征;60%以上的急性冠脉综合征住院发生于65岁以上患者。作为临床指南依据的大规模试验可能无法纳入像临床上那样多样化的患者人群。尤其是在对急性冠脉综合征治疗方法开展的当代临床试验中,老年人、女性和少数族群参与者的人数仍偏少4。登记系统和其他观察数据可能成为研究指南推荐疗法对各种患者人群所产生效应的有用工具。





作者信息

Fatima Rodriguez, M.D., M.P.H., and Robert A. Harrington, M.D.
From the Division of Cardiovascular Medicine, Department of Medicine, and the Stanford Cardiovascular Institute (F.R., R.A.H.), Stanford University, Palo Alto, CA. Address reprint requests to Dr. Harrington at the Department of Medicine, Stanford University, 300 Pasteur Dr., S102, MC:5110, Stanford, CA 94305, or at robert.harrington@stanford.edu.

 

参考文献

1. Crea F, Libby P. Acute coronary syndromes: the way forward from mechanisms to precision treatment. Circulation 2017;136:1155-1166.

2.Fuster V, Badimon L, Badimon JJ, Chesebro JH. The pathogenesis of coronary artery disease and the acute coronary syndromes. N Engl J Med 1992;326:242-250.

3.Virani SS, Alonso A, Benjamin EJ, et al. Heart disease and stroke statistics — 2020 update: a report from the American Heart Association. Circulation 2020;141(9):e139-e596.

4.Tahhan AS, Vaduganathan M, Greene SJ, et al. Enrollment of older patients, women, and racial/ethnic minority groups in contemporary acute coronary syndrome clinical trials: a systematic review. JAMA Cardiol 2020;5:714-722.

5.Amsterdam EA, Wenger NK, Brindis RG, et al. 2014 AHA/ACC guideline for the management of patients with non-ST-elevation acute coronary syndromes: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol 2014;64(24):e139-e228.

6.Roffi M, Patrono C, Collet J-P, et al. 2015 ESC guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation: Task Force for the Management of Acute Coronary Syndromes in Patients Presenting without Persistent ST-Segment Elevation of the European Society of Cardiology (ESC). Eur Heart J 2016;37:267-315.

7.O’Gara PT, Kushner FG, Ascheim DD, et al. 2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol 2013;61(4):e78-e140.

8.Ibanez B, James S, Agewall S, et al. 2017 ESC guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation: the Task Force for the management of acute myocardial infarction in patients presenting with ST-segment elevation of the European Society of Cardiology (ESC). Eur Heart J 2018;39:119-177.

9.Rodriguez F, Mahaffey KW. Management of patients with NSTE-ACS: a comparison of the recent AHA/ACC and ESC guidelines. J Am Coll Cardiol 2016;68:313-321.

10.Yusuf S, Zhao F, Mehta SR, Chrolavicius S, Tognoni G, Fox KK. Effects of clopidogrel in addition to aspirin in patients with acute coronary syndromes without ST-segment elevation. N Engl J Med 2001;345:494-502.

11.Mega JL, Close SL, Wiviott SD, et al. Cytochrome p-450 polymorphisms and response to clopidogrel. N Engl J Med 2009;360:354-362.

12.Karaźniewicz-Łada M, Danielak D, Główka F. Genetic and non-genetic factors affecting the response to clopidogrel therapy. Expert Opin Pharmacother 2012;13:663-683.

13.Simon T, Verstuyft C, Mary-Krause M, et al. Genetic determinants of response to clopidogrel and cardiovascular events. N Engl J Med 2009;360:363-375.

14.Paré G, Mehta SR, Yusuf S, et al. Effects of CYP2C19 genotype on outcomes of clopidogrel treatment. N Engl J Med 2010;363:1704-1714.

15.Roe MT, Armstrong PW, Fox KAA, et al. Prasugrel versus clopidogrel for acute coronary syndromes without revascularization. N Engl J Med 2012;367:1297-1309.

16.Wiviott SD, Braunwald E, McCabe CH, et al. Prasugrel versus clopidogrel in patients with acute coronary syndromes. N Engl J Med 2007;357:2001-2015.

17.Wiviott SD, White HD, Ohman EM, et al. Prasugrel versus clopidogrel for patients with unstable angina or non-ST-segment elevation myocardial infarction with or without angiography: a secondary, prespecified analysis of the TRILOGY ACS trial. Lancet 2013;382:605-613.

18.Wallentin L, Becker RC, Budaj A, et al. Ticagrelor versus clopidogrel in patients with acute coronary syndromes. N Engl J Med 2009;361:1045-1057.

19.Collet J-P, Thiele H, Barbato E, et al. 2020 ESC guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation. Eur Heart J 2020 August 29 (Epub ahead of print).

20.Schüpke S, Neumann F-J, Menichelli M, et al. Ticagrelor or prasugrel in patients with acute coronary syndromes. N Engl J Med 2019;381:1524-1534.

21.Levine GN, Bates ER, Bittl JA, et al. 2016 ACC/AHA guideline focused update on duration of dual antiplatelet therapy in patients with coronary artery disease: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines: an update of the 2011 ACCF/AHA/SCAI guideline for percutaneous coronary intervention, 2011 ACCF/AHA guideline for coronary artery bypass graft surgery, 2012 ACC/AHA/ACP/AATS/PCNA/SCAI/STS guideline for the diagnosis and management of patients with stable ischemic heart disease, 2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction, 2014 AHA/ACC guideline for the management of patients with non-ST-elevation acute coronary syndromes, and 2014 ACC/AHA guideline on perioperative cardiovascular evaluation and management of patients undergoing noncardiac surgery. Circulation 2016;134(10):e123-e155.

22.Marquis-Gravel G, Roe MT, Robertson HR, et al. Rationale and design of the Aspirin Dosing-A Patient-Centric Trial Assessing Benefits and Long-term Effectiveness (ADAPTABLE) trial. JAMA Cardiol 2020;5:598-607.

23.Furtado RHM, Nicolau JC, Magnani G, et al. Long-term ticagrelor for secondary prevention in patients with prior myocardial infarction and no history of coronary stenting: insights from PEGASUS-TIMI 54. Eur Heart J 2020;41:1625-1632.

24.Palmerini T, Bruno AG, Gilard M, et al. Risk-benefit profile of longer-than-1-year dual-antiplatelet therapy duration after drug-eluting stent implantation in relation to clinical presentation. Circ Cardiovasc Interv 2019;12(3):e007541-e007541.

25.Yeh RW, Kereiakes DJ, Steg PG, et al. Benefits and risks of extended duration dual antiplatelet therapy after PCI in patients with and without acute myocardial infarction. J Am Coll Cardiol 2015;65:2211-2221.

26.Bonaca MP, Bhatt DL, Cohen M, et al. Long-term use of ticagrelor in patients with prior myocardial infarction. N Engl J Med 2015;372:1791-1800.

27.O’Donoghue ML, Murphy SA, Sabatine MS. The safety and efficacy of aspirin discontinuation on a background of a P2Y12 inhibitor in patients after percutaneous coronary intervention: a systematic review and meta-analysis. Circulation 2020;142:538-545.

28.Tomaniak M, Chichareon P, Onuma Y, et al. Benefit and risks of aspirin in addition to ticagrelor in acute coronary syndromes: a post hoc analysis of the randomized GLOBAL LEADERS Trial. JAMA Cardiol 2019;4:1092-1101.

29.Vranckx P, Valgimigli M, Jüni P, et al. Ticagrelor plus aspirin for 1 month, followed by ticagrelor monotherapy for 23 months vs aspirin plus clopidogrel or ticagrelor for 12 months, followed by aspirin monotherapy for 12 months after implantation of a drug-eluting stent: a multicentre, open-label, randomised superiority trial. Lancet 2018;392:940-949.

30.Mehran R, Baber U, Sharma SK, et al. Ticagrelor with or without aspirin in high-risk patients after PCI. N Engl J Med 2019;381:2032-2042.

31.Kim B-K, Hong S-J, Cho Y-H, et al. Effect of ticagrelor monotherapy vs ticagrelor with aspirin on major bleeding and cardiovascular events in patients with acute coronary syndrome: the TICO randomized clinical trial. JAMA 2020;323:2407-2416.

32.Andreotti F, Testa L, Biondi-Zoccai GGL, Crea F. Aspirin plus warfarin compared to aspirin alone after acute coronary syndromes: an updated and comprehensive meta-analysis of 25,307 patients. Eur Heart J 2006;27:519-526.

33.Alexander JH, Lopes RD, James S, et al. Apixaban with antiplatelet therapy after acute coronary syndrome. N Engl J Med 2011;365:699-708.

34.Hess CN, James S, Lopes RD, et al. Apixaban Plus Mono Versus Dual Antiplatelet Therapy in Acute Coronary Syndromes: Insights From the APPRAISE-2 Trial. J Am Coll Cardiol 2015;66:777-787.

35.Mega JL, Braunwald E, Wiviott SD, et al. Rivaroxaban in patients with a recent acute coronary syndrome. N Engl J Med 2012;366:9-19.

36.Eikelboom JW, Connolly SJ, Bosch J, et al. Rivaroxaban with or without aspirin in stable cardiovascular disease. N Engl J Med 2017;377:1319-1330.

37.Capodanno D, Huber K, Mehran R, et al. Management of antithrombotic therapy in atrial fibrillation patients undergoing PCI: JACC state-of-the-art review. J Am Coll Cardiol 2019;74:83-99.

38.January CT, Wann LS, Calkins H, et al. 2019 AHA/ACC/HRS focused update of the 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society. J Am Coll Cardiol 2019;74:104-132.

39.Rathore SS, Berger AK, Weinfurt KP, et al. Acute myocardial infarction complicated by atrial fibrillation in the elderly: prevalence and outcomes. Circulation 2000;101:969-974.

40.Goldberg RJ, Seeley D, Becker RC, et al. Impact of atrial fibrillation on the in-hospital and long-term survival of patients with acute myocardial infarction: a community-wide perspective. Am Heart J 1990;119:996-1001.

41.Crenshaw BS, Ward SR, Granger CB, Stebbins AL, Topol EJ, Califf RM. Atrial fibrillation in the setting of acute myocardial infarction: the GUSTO-I experience: Global Utilization of Streptokinase and TPA for Occluded Coronary Arteries. J Am Coll Cardiol 1997;30:406-413.

42.Hess CN, Peterson ED, Peng SA, et al. Use and outcomes of triple therapy among older patients with acute myocardial infarction and atrial fibrillation. J Am Coll Cardiol 2015;66:616-627.

43.Hansen ML, Sørensen R, Clausen MT, et al. Risk of bleeding with single, dual, or triple therapy with warfarin, aspirin, and clopidogrel in patients with atrial fibrillation. Arch Intern Med 2010;170:1433-1441.

44.Sørensen R, Hansen ML, Abildstrom SZ, et al. Risk of bleeding in patients with acute myocardial infarction treated with different combinations of aspirin, clopidogrel, and vitamin K antagonists in Denmark: a retrospective analysis of nationwide registry data. Lancet 2009;374:1967-1974.

45.Sarafoff N, Martischnig A, Wealer J, et al. Triple therapy with aspirin, prasugrel, and vitamin K antagonists in patients with drug-eluting stent implantation and an indication for oral anticoagulation. J Am Coll Cardiol 2013;61:2060-2066.

46.Dewilde WJM, Oirbans T, Verheugt FW, et al. Use of clopidogrel with or without aspirin in patients taking oral anticoagulant therapy and undergoing percutaneous coronary intervention: an open-label, randomised, controlled trial. Lancet 2013;381:1107-1115.

47.Gibson CM, Mehran R, Bode C, et al. Prevention of bleeding in patients with atrial fibrillation undergoing PCI. N Engl J Med 2016;375:2423-2434.

48.Cannon CP, Bhatt DL, Oldgren J, et al. Dual antithrombotic therapy with dabigatran after PCI in atrial fibrillation. N Engl J Med 2017;377:1513-1524.

49.Lopes RD, Heizer G, Aronson R, et al. Antithrombotic therapy after acute coronary syndrome or PCI in atrial fibrillation. N Engl J Med 2019;380:1509-1524.

50.Alexander JH, Wojdyla D, Vora AN, et al. Risk/benefit tradeoff of antithrombotic therapy in patients with atrial fibrillation early and late after an acute coronary syndrome or percutaneous coronary intervention: insights from AUGUSTUS. Circulation 2020;141:1618-1627.

51.Vranckx P, Valgimigli M, Eckardt L, et al. Edoxaban-based versus vitamin K antagonist-based antithrombotic regimen after successful coronary stenting in patients with atrial fibrillation (ENTRUST-AF PCI): a randomised, open-label, phase 3b trial. Lancet 2019;394:1335-1343.

52.Khan SU, Osman M, Khan MU, et al. Dual versus triple therapy for atrial fibrillation after percutaneous coronary intervention: a systematic review and meta-analysis. Ann Intern Med 2020;172:474-483.

53.Yasuda S, Kaikita K, Akao M, et al. Antithrombotic therapy for atrial fibrillation with stable coronary disease. N Engl J Med 2019;381:1103-1113.

54.Piccolo R, Gargiulo G, Franzone A, et al. Use of the dual-antiplatelet therapy score to guide treatment duration after percutaneous coronary intervention. Ann Intern Med 2017;167:17-25.

55.Yeh RW, Secemsky EA, Kereiakes DJ, et al. Development and validation of a prediction rule for benefit and harm of dual antiplatelet therapy beyond 1 year after percutaneous coronary intervention. JAMA 2016;315:1735-1749.

56.Kereiakes DJ, Yeh RW, Massaro JM, et al. DAPT score utility for risk prediction in patients with or without previous myocardial infarction. J Am Coll Cardiol 2016;67:2492-2502.

57.Costa F, van Klaveren D, James S, et al. Derivation and validation of the predicting bleeding complications in patients undergoing stent implantation and subsequent dual antiplatelet therapy (PRECISE-DAPT) score: a pooled analysis of individual-patient datasets from clinical trials. Lancet 2017;389:1025-1034.

58.Bergmeijer TO, Janssen PWA, van Oevelen M, et al. Incidence and causes for early ticagrelor discontinuation: a “Real-World” Dutch Registry experience. Cardiology 2017;138:164-168.

59.De Servi S, Roncella A, Reimers B. Causes and clinical implications of premature discontinuation of dual antiplatelet therapy. Curr Opin Cardiol 2011;26:Suppl 1:S15-S21.

60.Wang TY, Kaltenbach LA, Cannon CP, et al. Effect of medication co-payment vouchers on P2Y12 inhibitor use and major adverse cardiovascular events among patients with myocardial infarction: the ARTEMIS randomized clinical trial. JAMA 2019;321:44-55.

61.Fosbøl EL, Ju C, Anstrom KJ, et al. Early cessation of adenosine diphosphate receptor inhibitors among acute myocardial infarction patients treated with percutaneous coronary intervention: insights from the TRANSLATE-ACS study (Treatment with Adenosine Diphosphate Receptor Inhibitors: Longitudinal Assessment of Treatment Patterns and Events after Acute Coronary Syndrome). Circ Cardiovasc Interv 2016;9(11):e003602-e003602.

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