急性冠脉综合征抗栓治疗出血情况研究现状

抗栓治疗在显著降低急性冠脉综合征患者不良心血管事件发生率的同时,也增加了出血的风险。大出血往往增加患者死亡率及再发缺血事件,影响临床预后。肾功能不全、低体重等是出血的危险因素,针对患者情况进行个性化抗栓治疗或引进应用新型抗栓药物,可能会减少出血并发症。     

急性冠脉综合征抗栓治疗出血情况研究现状

抗栓治疗在显著降低急性冠脉综合征患者不良心血管事件发生率的同时,也增加了出血的风险。大出血往往增加患者死亡率及再发缺血事件,影响临床预后。肾功能不全、低体重等是出血的危险因素,针对患者情况进行个性化抗栓治疗或引进应用新型抗栓药物,可能会减少出血并发症。     

围消化道内镜操作期抗栓药物应用的管理与思考

使用抗栓药物患者行消化道内镜检查或治疗时，消化道内镜医师为避免消化道出血风险，倾向于在检查前停用抗栓药物。但患者中断抗栓药物治疗，却可能导致心脑血管血栓栓塞事件增加的风险。故围消化道内镜操作期抗栓药物的管理值得关注及思考。     

口服联合抗栓药物治疗的现况和进展

该文介绍各种联合抗栓治疗方案的研究现况。华法林联用氯吡格雷在不增加血栓栓塞风险的同时,减少了出血风险。以新型口服抗凝药物或者新型抗血小板药物为基础的三联抗栓治疗有增加出血风险的倾向,但相关临床试验较少,需要进一步研究。     

老年冠心病患者的抗栓治疗

抗栓治疗可使冠心病患者明显获益,老年冠心病患者接受抗栓药物治疗获益的同时,出血的风险较非老年患者明显增高。对老年冠心病患者应用抗栓药物,应当熟知其作用机制,谨慎权衡抗栓药物的有效性和安全性。在治疗过程中需重视监测出血副作用,给药剂量和联合用药方案力争实现个体化,使其既达到预期的治疗效果,又能避免出血等不良事件的发生。     

慢性肾功能不全与急性冠状动脉综合征的研究进展

大量的研究证实急性冠状动脉综合征(ACS)患者合并肾功能异常较为常见,肾功能不全是ACS患者不良预后的独立危险因素,然而其具体的机制目前还不是很清楚。肾功能状态影响着ACS患者的治疗策略,包括介入、抗栓及抗凝药物的使用等。现对肾功能不全造成不良预后的相关病理生理机制及ACS合并肾功能不全患者的治疗现状做一综述,重视ACS患者的肾功能评估,以其更好地指导治疗,改善患者预后。     

老年房颤患者的抗栓治疗

<正>近10余年来,大量循证医学证据显示,抗栓治疗可使心房颤动(房颤)患者明显获益。2010年ESC房颤治疗指南中,已将房颤的抗栓治疗摆在了房颤三大治疗之首,这足以显示抗栓治疗的重要性[1]。但是,老年房颤患者抗栓治疗获益的同时,有较高的出血风险。此外,老年人往往罹患多种疾病而服多种药物,药物之间的相互作用,可能影响抗栓药物的代谢和疗效。老年患者的各种高危因素,使抗栓治疗复     

冠心病伴慢性肾脏病患者抗栓治疗的研究进展

冠心病是一种严重影响人类健康的全球性疾病,而慢性肾脏病增加冠心病患者,尤其是急性冠状动脉综合征患者的出血及死亡风险。对此类患者进行抗栓治疗时需要权衡利弊,因此规范化抗栓治疗,选择合理的抗栓药物,在冠心病的预防和治疗中起着重要作用。本文将结合众多大型临床试验研究结果,从慢性肾脏病患者血栓形成和止血的机制、抗栓药物治疗及临床实践建议等方面,阐述冠心病伴慢性肾病抗栓治疗的策略。     

达比加群酯在冠心病PCI合并心房颤动高出血风险患者抗栓治疗中的作用

目的探讨达比加群酯在冠心病PCI合并心房颤动高出血风险患者抗栓治疗中的疗效及安全性研究。方法选择冠心病冠状动脉介入治疗(PCI)合并心房颤动高出血风险患者140例,随机分为达比加群酯组和对照组。两组PCI开始至术后4周,均给予三联抗血栓药物治疗,术后4周～12月给予双联抗血栓药物治疗。其中达比加群酯组给予达比加群酯治疗,对照组给予华法林治疗。比较两组患者PCI前后的血小板计数、凝血功能、肝功能、肾功能,同时观察出血事件及血栓栓塞事件。结果两组血小板计数、血浆D二聚体、纤维蛋白原(FIB)、肝功能、肾功能治疗前后比较,差异无统计学意义(P0.05)。两组治疗后与治疗前比较,活化部分凝血酶原时间(APTT)均升高;与对照组比较,达比加群酯组升高更显著(P0.05)。两组治疗后与治疗前比较,国际标准化比值(INR)均升高;与达比加群酯组比较,对照组升高更显著,且维持在达标水平(2.0～3.0)(P0.05)。与对照组比较,达比加群酯组患者出血事件及血栓栓塞事件的发生率明显低于对照组(P0.05)。结论对于冠心病PCI合并心房颤动高出血风险患者抗栓治疗中,抗血小板药物联合达比加群酯治疗,与华法林比较,能更有效预防血栓栓塞事件,同时显著降低出血事件的发生率。     

未来心房颤动抗栓——谁主沉浮

心房颤动(房颤)是导致缺血性脑卒中的主要危险因素,因此抗栓治疗是房颤治疗的核心.目前临床上最常用的抗栓药物是华法林,但其具有治疗窗窄、易出血、需定期监测凝血功能等缺陷,需要我们去积极探索新的抗栓药物.直接凝血酶抑制剂、Xa因子抑制剂及REG1等药物的发现给房颤抗栓治疗带来了新的曙光.这些药物大多已被多项临床试验结果证明具有抗栓作用,且可以弥补华法林的不足,至于能否替代华法林用于房颤的抗栓治疗,有待正在进行或正在积极准备的相关研究来回答.现回顾近年来相关临床研究的结果,分析目前新型抗凝药物中谁最有可能主导未来房颤的抗栓治疗.     

房颤并发冠心病的抗栓策略

栓塞和血栓形成是房颤(AF)和冠心病的常见并发症,所以对于AF并发冠心病患者进行抗栓治疗就至关重要。治疗AF需要口服抗凝剂以减少缺血性卒中,而对冠心病患者则需要长期抗血小板治疗以减少冠状动脉事件。对于AF并发冠心病的患者,如何平衡抗凝或（联合）抗血小板的获益与出血风险？已成为临床讨论的焦点。本文结合2010年《ESC心房颤动治疗指南》及当前的询证学依据,详细综述了AF并发冠心病这一类栓塞高危人群的抗栓治疗策略。     

Concomitant Use of Antiplatelets and Anticoagulants in Patients with Coronary Heart Disease and Atrial Fibrillation: What Do Recent Clinical Trials Teach Us?

Purpose of Review

Coronary heart disease (CHD) and atrial fibrillation (AF) are among the most common cardiovascular diseases. A significant proportion of patients have both CHD and AF and are at increased risk for thrombotic complications. Current therapy for CHD and AF includes antiplatelet and anticoagulant medications, respectively. Patients with concurrent CHD and AF may be prescribed dual antiplatelet therapy (DAPT) in addition to anticoagulation, which increases their bleeding risk. Controversy remains on how to balance risks and benefits in patients with CHD and AF in which multiple antithrombotic therapies may be indicated.

Recent Findings

We review clinical trials and current guidelines for antiplatelet and anticoagulant therapy in CHD and AF. Aspirin and P2Y₁₂ inhibitors are the mainstay of antiplatelet therapy. Vitamin K antagonists (VKAs) are the most commonly used anticoagulant, although the use of non-VKA oral anticoagulants (NOACs) in patients with AF is increasing. Recent studies provide guidance on how to address antithrombotic therapies in patients with concomitant CHD and AF. To date, we have evidence that in patients with AF who undergo percutaneous coronary intervention (PCI), clopidogrel with VKA may be used safely without aspirin. Also, low-dose rivaroxaban in combination with either clopidogrel only or DAPT is as effective as the traditional regimen of triple therapy with VKA and DAPT with lower bleeding risk. Dabigatran with a P2Y₁₂ inhibitor was also found to be safe with less bleeding compared to triple therapy with VKA and DAPT.

Summary

Use of a single antiplatelet agent with anticoagulation has become a viable choice in patients with CHD and AF, but more clinical trial data is needed to confirm therapy and duration regimens.

     

75岁以上老年非瓣膜病心房颤动患者抗血栓治疗的应用现状

目的对于我院>75岁老年非瓣膜病心房颤动(房颤)患者抗血栓药物治疗的情况进行调查,了解用药现状。方法调查>75岁非瓣膜病房颤患者125例,对其危险因素及抗血栓药物使用情况进行分析。结果125例患者中,合并多种危险因素者多见,其中应用华法林者只有30例(24.0%),应用阿司匹林者54例(43.2%),其他抗血小板药物29例(23.2%),未应用抗血栓药物12例(9.6%)。阿司匹林及其他抗血小板口服药剂量为每天75~100 mg。结论>75岁老年非瓣膜病房颤患者华法林应用率低,抗血小板药使用率高,但用药剂量偏小。     

心房颤动合并冠心病患者抗栓治疗分析

目的 探讨非瓣膜病心房颤动合并冠心病患者抗栓治疗方案及华法林治疗后大出血发生情况.方法 回顾性分析2005年1月至2009年12月北京同仁医院住院的非瓣膜病心房颤动合并冠心病患者134例,记录基线特征、抗凝和抗血小板治疗方案,门诊或电话随访血栓栓塞、出血及主要心脏事件发生情况.结果 134例患者年龄(73.8±7.8)...     

心房颤动合并冠心病并PCI患者三联与二联抗栓治疗的安全性和疗效比较

目的：对比观察心房颤动（AF）合并冠心病PCI术后患者三联抗栓治疗与双联栓治疗的安全性和有效性。方法：连续入选180例AF合并冠心病PCI术后患者,根据服用的抗栓药物分成两组：三联抗栓组[60例,服用阿司匹林（100mg/d）、氯吡格雷（75mg/d）和华法林],双联抗栓组[120例,服用阿司匹林（100mg/d）和氯吡格雷（75mg/d）],两组其他冠心病二级预防措施相同。对随访期间发生的出血事件、血栓栓塞事件以及主要不良心血管事件（MACE）进行统计分析。结果：所有患者中,168例（93.3%）完成了至少一年期随访。随访期间,两组出血事件发生率未达显著差异（18.3%比11.7%,P〉0.05）,三联抗栓组较双联抗栓组严重出血事件发生率增加3倍（3.3%比0.8%）,但无显著差异（P〉0.05）。Cox回归分析表明,年龄（HR 0.59,95%CI 0.40～0.83,P=0.025）和使用华法林（HR 1.33,95%CI 0.88～2.54,P=0.016）是随访1年期间出血事件的独立危险因素。两组MACE发生率差异无显著性（P〉0.05）。结论：对于房颤合并冠心病并PCI术后的患者,三联与二联抗栓治疗的安全性及疗效虽无显著差异,但三联抗栓治疗严重出血有增加的倾向,而且华法林是出血事件的独立危险因素,所以对于此类患者还是使用二联抗栓治疗为宜。     

Antithrombotic Management of Elderly Patients With Coronary Artery Disease

Antithrombotic therapy represents the mainstay of treatment in patients with coronary artery disease (CAD), including elderly patients who are at increased risk for ischemic recurrences. However, the elderly population is also more vulnerable to bleeding complications. Numerous mechanisms, including abnormalities in the vasculature, thrombogenicity, comorbidities, and altered drug response, contribute to both increased thrombotic and bleeding risk. Age-related organ changes and drug-drug interactions secondary to polypharmacy lead to distinct pharmacokinetic and pharmacodynamic profiles of antithrombotic drugs. Overall these factors contribute to the risk-benefit profiles of antithrombotic therapies in elderly subjects and underscore the need for treatment regimens that can reduce bleeding while preserving efficacy. Given that the prevalence of CAD, as well as concomitant diseases with thromboembolic potential, such as atrial fibrillation, increases with age and that the elderly population is in continuous growth, understanding the safety and efficacy of different antithrombotic regimens is pivotal for patient-centered care. In the present overview the authors appraise the available data on the use of antithrombotic therapy in older patients with CAD to assist with the management of this high-risk population and define knowledge gaps that can set the basis for future research.     

The impact of bleeding in patients with acute coronary syndromes: how to optimize the benefits of treatment and minimize the risk

Recurrent ischemic events after an acute coronary syndrome (ACS) remain common. Antithrombotic therapy with coronary revascularization reduces the frequency of such life-threatening events. However, with the greater use of antithrombotic medications and early revascularization, bleeding has become an increasingly important problem. Not only does bleeding result in an immediate threat, but it is also associated with increased coronary artery disease mortality and reinfarction, both in the short and long term. Older patients and women, as well as patients with anemia, renal dysfunction, high-risk ACS, diabetes, hypertension and those undergoing invasive procedures, are at especially high risk for bleeding. Major bleeding is associated with a 60% increased risk of in-hospital death, and a fivefold increase in one-year mortality and reinfarction. However, the causal link between bleeding and increased coronary artery disease events is unproven. Although there is no proof that reducing bleeding events improves outcomes, the current paradigm for the management of ACS is a strategy to minimize recurrent ischemic events but also to minimize the risk of bleeding. Such a strategy includes matching the ACS risk to the most appropriate treatment, assessing the bleeding risk, using vascular access techniques to minimize bleeding, selecting the antithrombotic agent that is best for the patient, minimizing the duration of exposure to antithrombotic agents, using the correct dose of medications, recognizing the early signs of bleeding and using gastroprotective agents to minimize upper gastrointestinal bleeding.     

Should patients with hypertension receive antithrombotic therapy?

The main complications of hypertension, i.e. coronary heart disease, ischaemic strokes and peripheral vascular disease (PVD), are usually related to thrombosis. Increasing evidence also suggests that hypertension fulfils the components of Virchow's triad, thus conferring a prothrombotic or hypercoagulable state, as evident by abnormalities of haemostasis, platelets and endothelial function. It therefore seems plausible that use of antithrombotic therapy may help prevent these thrombosis-related complications of hypertension. Indeed, hypertensive patients with an estimated 10-year CHD risk > or = 15% will have their cardiovascular risk reduced by 25% using antihypertensive treatment, but the addition of aspirin further reduces major cardiovascular events by 15%. Recent guidelines recommend the use of aspirin 75 mg daily for hypertensive patients who have no contraindication to aspirin, in one of the following categories: (i) secondary prevention - cardiovascular complications (myocardial infarction, angina, non-haemorrhagic stroke, peripheral vascular disease or atherosclerotic renovascular disease); and (ii) primary prevention - those with blood pressure controlled to < 150/90 mmHg and one of: (a) age > or = 50 years and target organ damage (e.g. LVH, renal impairment, or proteinuria); (b) a 10-year CHD risk > or = 15%; or (c) type II diabetes mellitus. However, some of the risks of aspirin administration, namely increased incidence of major bleeding events, may possibly outweigh the benefits, especially in low-risk individuals.     

Balancing the risks of stroke and upper gastrointestinal tract bleeding in older patients with atrial fibrillation

OBJECTIVE: To determine how factors that increase the risk of major upper gastrointestinal (GI) tract hemorrhage (recent upper GI tract bleeding or concurrent use of nonsteroidal anti-inflammatory drugs) influence the choice of antithrombotic therapy in older patients (those > or = 65 years) with atrial fibrillation. METHODS: For older patients with atrial fibrillation and no other contraindications to antithrombotic therapy, a Markov decision-analytic model was used to determine the preferred treatment strategy (no antithrombotic therapy, long-term aspirin use, or long-term warfarin sodium use) based on their risk of major upper GI tract hemorrhage. Input data were obtained by a systematic review of MEDLINE. Outcomes were expressed as quality-adjusted life-years (QALYs). RESULTS: For 65-year-old patients with average risks of stroke and upper GI tract bleeding, warfarin therapy was associated with 12.1 QALYs per patient; aspirin therapy, 10.8 QALYs; and no antithrombotic therapy, 10.1 QALYs. For persons with significantly higher risks of upper GI tract bleeding and/or lower risks of stroke, warfarin was no longer clearly the optimal antithrombotic therapy (eg, for 80-year-old persons with a baseline risk of stroke of 4.3% per year who were concurrently taking a conventional nonsteroidal anti-inflammatory drug: warfarin, 7.44 QALYs; aspirin, 7.39 QALYs; and no treatment, 7.21 QALYs). CONCLUSIONS: For older patients with atrial fibrillation and factors that place them at a higher than average risk of upper GI tract bleeding, the optimal choice of antithrombotic therapy to prevent stroke can vary according to the magnitude of this risk. Based on the risks of stroke and upper GI tract bleeding, clinicians can use the treatment recommendations of this study to provide rational stroke prevention therapy for older patients with atrial fibrillation.