心房颤动合并冠心病患者支架置入术后的抗栓治疗

约20%～30%的心房颤动患者合并冠心病,其中至少5%～7%行冠状动脉支架置入治疗。心房颤动合并冠心病患者支架置入术后需要同时抗凝和抗血小板治疗,平衡血栓事件与出血风险是制定治疗方案的关键。多项临床研究提到,口服抗凝药联合一种抗血小板药将成为三联抗栓治疗的替代治疗方案,但由于样本量不足,尚不能支撑临床决策和个人抗栓方案的制定。大规模、多中心、随机、双盲、高质量的临床试验仍有待出现。     

三联抗栓治疗在冠心病患者中的合理应用

冠状动脉内支架置入术后患者常规需接受阿司匹林＋氯吡格雷的双联抗血小板治疗,而当患者同时存在抗凝治疗指征时,则需要阿司匹林＋氯吡格雷＋华法林的三联抗栓治疗,但随之而来的是显著出血风险。该文主要介绍三联抗栓治疗在冠心病患者中的合理应用。     

左心耳封堵术对非瓣膜性心房颤动合并冠状动脉性心脏病的价值

非瓣膜性心房颤动合并冠状动脉性心脏病患者的抗栓策略目前尚存争议,部分患者面临高缺血和/或高出血风险。现有指南大多推荐心房颤动合并急性冠脉综合征和/或经皮冠状动脉介入治疗患者应于早期接受三联抗栓治疗,推荐心房颤动合并慢性冠脉综合征患者接受单联口服抗凝药物预防缺血性心脑血管事件,但缺血与出血事件的有效平衡仍是临床中的棘手问题。左心耳封堵术作为心房颤动患者的抗凝替代治疗可同时减少缺血和出血事件,或可改变心房颤动合并冠状动脉性心脏病患者的治疗格局,现就这一领域的相关进展做一综述。     

心房颤动患者卒中的药物预防策略——Missouri-Columbia大学心血管病中心

卒中是心房颤动的严重并发症。以往的预防措施包括口服阿司匹林和抗凝药。对不适合口服抗凝药的患者可以采用阿司匹林和氯吡格雷的联合治疗。但这种联合治疗在降低卒中风险的同时,却增加了出血的风险。对于心房颤动合并有不稳定型冠脉综合征者,或接受冠状动脉支架治疗,但又不适合接受三联治疗（阿司匹林、氯吡格雷、华法林）的患者,该中心采用阿司匹林和氯吡格雷。对于冠状动脉支架手术,要求介入专家优先考虑采用裸金属支架,以缩短患者依赖联合治疗的时间。     

目前冠心病合并房颤患者抗栓治疗的观点和焦点

根据冠心病合并心房颤动(房颤)患者缺血和出血的风险评估,制定个体化抗栓策略至关重要。房颤合并急性冠状动脉综合征或冠状动脉介入术后需3联抗栓治疗。长期持续的抗栓治疗策略还取决于患者临床情况、支架种类、抗栓药物类型等。合理选择手术路径、抗栓药物、支架种类以及有效的临床监测和质子泵抑制剂可以明显降低患者的临床风险。     

长期口服抗凝药物治疗的患者经皮冠状动脉支架置入术后的抗栓治疗

目前阿司匹林和氯毗格雷的双联抗血小板治疗已经成为冠状动脉支架置入术后的标准抗栓方案,但约有5%接受冠状动脉支架置人术的患者需要长期口服维生素K拮抗剂治疗,对这些患者的抗栓治疗方案尚未统一,也是困扰心内科医师的难题之一.本文总结了接受长期口服抗凝药物治疗的患者行冠状动脉支架置入术后多种抗栓治疗方法,以寻求对此类患者的最佳治疗方案.     

心房颤动合并慢性冠状动脉综合征的抗栓治疗进展

心房颤动和慢性冠状动脉综合征常合并存在,二者并存时不仅增加卒中和体循环栓塞风险,且心脏缺血事件风险亦高.对于心房颤动合并慢性冠状动脉综合征患者,采取何种抗栓策略及如何权衡缺血及出血风险是临床上亟待明确的问题.近年来针对抗栓治疗的研究越来越多,现结合最新研究证据就心房颤动合并慢性冠状动脉综合征的抗栓治疗做一综述.     

非瓣膜性心房颤动患者PCI术后双联抗栓治疗最新进展

大约有10%的非瓣膜性心房颤动(NVAF)患者接受经皮冠状动脉介入治疗(PCI)。该类患者栓塞事件发生率很高,需要抗凝联合抗血小板治疗。临床上NVAF患者PCI术后通常采用口服抗凝药(OAC)+阿司匹林+氯吡格雷三联抗栓治疗(TAT)。TAT虽然能有效预防栓塞事件发生,但存在高出血风险。研究显示新型口服抗凝药(NOACs)联合氯吡格雷双联抗栓治疗(DAT)抗栓疗效不劣于TAT,且出血风险明显降低。尽管如此,目前指南对于NVAF患者PCI术后抗栓治疗仍存在部分争议。本文就NVAF患者PCI术后DAT与TAT的安全性及有效性进行综述,以指导临床上该类患者合理选择抗栓策略。     

冠心病介入抗栓治疗相关最新进展概要

近年经皮冠状动脉介入治疗（PCI）相关抗栓领域取得了许多关键性的进展。以TWILIGHT等研究为代表的降阶治疗探索是目前PCI术后抗血小板策略研究的主流方向之一,而在合并心房颤动PCI患者中,联合新型口服抗凝药物的双联或短程三联抗栓方案的有效和安全性已获多项新研究的印证。比伐芦定新的研究结果将更新直接PCI抗凝的循证证...     

基于利伐沙班的不同疗程三联抗栓方案对ACS合并AF的老年患者PCI后远期预后的影响

目的探讨不同疗程的利伐沙班联合双抗血小板药物的三联抗栓治疗对接受经皮冠状动脉介入治疗(PCI)的急性冠脉综合征(ACS)合并心房颤动(AF)的老年患者远期预后的影响。方法按照纳入及排除原则选取2017年4月至2019年3月于漯河市中心医院重症监护病房收治的ACS合并AF患者240例作为研究对象,随机分为三联抗栓6个月组(观察组)和三联抗栓1个月组(对照组)各120例,每组在结束三联抗栓疗程后立即过渡为利伐沙班联合单抗血小板治疗方案,连续随访12个月。记录随访期间出血事件、死亡、缺血性卒中及主要不良心血管事件(MACE)的发生情况和发生日期。结果两组患者总出血事件及根据ISTH分级原则进行分级,各种程度出血事件均无统计学差异(P0.05);两组患者的总MACE事件发生率无统计学差异(P0.05),但PCI后再发心肌梗死与再次血运重建方面,两组间存在显著差异(P0.05)。结论对于PCI后ACS合并AF的老年患者,延长基于利伐沙班的三联抗栓下的双抗血小板药物使用时间是安全的,但缩短双抗血小板疗法(DAPT)时间可能增加老年ACS患者PCI后冠状动脉疾病再度恶化风险。     

Registro observacional prospectivo sobre la utilización del tratamiento antitrombótico durante el periodo perioperatorio y periprocedimiento en el «mundo real»: estudio REQXAA

Introduction and objectivesThere is scarce real-world evidence on the management of perioperative antithrombotic treatment according to current recommendations. The aim of this study was to analyze the management of antithrombotic treatment in patients undergoing surgery or another invasive intervention and to assess the consequences of this management on the occurrence thrombotic or bleeding events.MethodsThis prospective, observational, multicenter and multispecialty study analyzed patients receiving antithrombotic therapy who underwent surgery or another invasive intervention. The primary endpoint was defined as the incidence of adverse (thrombotic and/or hemorrhagic) events after 30 days of follow-up with respect to management of perioperative antithrombotic drugs.ResultsWe included 1266 patients (male: 63.5%; mean age 72.6 years). Nearly half of the patients (48.6%) were under chronic anticoagulation therapy (mainly for atrial fibrillation; CHA₂DS₂-VAS_C: 3.7), while 53.3% of the patients were under chronic antiplatelet therapy (mainly for coronary artery disease). Low ischemic and hemorrhagic risk was found in 66.7% and 51.9%, respectively. Antithrombotic therapy management was in line with current recommendations in only 57.3% of the patients. Inappropriate management of antithrombotic therapy was an independent risk factor for both thrombotic and hemorrhagic events.ConclusionsThe implementation of recommendations on the perioperative/periprocedural management of antithrombotic therapy in real-world patients is poor. Inappropriate management of antithrombotic treatment is associated with an increase in both thrombotic and hemorrhagic events.     

Systematic Review of Observational Research Studying the Long‐Term use of Antithrombotic Medicines Following Intracerebral Hemorrhage

Patients with intracerebral hemorrhage frequently have indications for antithrombotic therapy. This represents a therapeutic dilemma as intracerebral hemorrhage is considered a contraindication to antithrombotic medication. Previous systematic reviews have revealed no long‐term randomised studies addressing this issue. Our objective was to review observational studies describing the long‐term follow‐up of patients receiving antithrombotic therapy following intracerebral hemorrhage. Searches were conducted in MEDLINE and EMBASE from 1984 to 2008 for any observational studies detailing use of antithrombotic treatments in patients with intracerebral hemorrhage. Included studies must have had follow‐up extending beyond discharge. The primary endpoint was recurrent intracerebral hemorrhage. Secondary endpoints were ischemic events and serious vascular events. 1,301 articles were reviewed: two epidemiological studies and six case series met the inclusion criteria. These described a total of 46 subjects receiving antiplatelet agents (from one study) and 42 patients receiving oral anticoagulants (from one study and six case‐series). For patients receiving subsequent aspirin there were seven recurrent intracerebral hemorrhages and four subsequent thrombo‐occulsive events. Amongst patents restarting oral anticoagulation there were four recurrent intracerebral bleeds and nine subsequent thrombo‐occulsive events. There is a marked paucity of evidence to guide clinicians when planning the long‐term management of patients with intracerebral hemorrhage and cogent indications for antithrombotic therapy. Published guidance addressing this issue is not evidence based. In the continued absence of randomised studies addressing antithrombotic use following intracerebral hemorrhage, there is a clear requirement for further high quality observational data on the clinical impact of antithrombotic therapy in this important patient group.     

Quality of life in children requiring antithrombotic therapy: development of a measure

Measurement of quality of life (QOL) has been accepted as an important outcome measure in therapeutic clinical trials. Long-term antithrombotic therapy is hypothesized to induce treatment dissatisfaction and influence QOL. Health-related quality of life (HRQOL) can be measured by an inventory developed specific to the patient condition. Pediatric QOL inventory for children on long-term antithrombotic therapy should assess constructs salient for this population. Creation of an HRQOL measurement inventory requires rigor and methodological adherence. Identification and evaluation of QOL constructs is critical to improve care and is accepted as the "gold standard" measurement for patient-centered outcomes in clinical research. The use of a valid and reliable HRQOL inventory specific for the antithrombotic therapy is required for upcoming clinical trials as it will provide a method to measure change in HRQOL specific to the antithrombotic agent. In this way, it will be possible to provide the child/family with information to make safe and effective therapeutic choices, define future antithrombotic therapy research strategies, and inform decision makers to change policies to improve health care.     

Prevention of gastrointestinal events in patients on antithrombotic therapy in the peri‐endoscopy period: Review of new evidence and recommendations from recent guidelines

Management of patients on antithrombotic therapy undergoing endoscopic procedures can be challenging. Although guidelines from major gastrointestinal endoscopy societies provide useful recommendations in this regard, data are limited concerning the bleeding risk of new complex endoscopic procedures and the management of novel anticoagulants in patients needing invasive procedures. The approach to the management of antithrombotic therapy often needs to be formulated on an individual basis, especially in patients with high thrombotic risk undergoing a high‐risk endoscopic procedure. In addition to the procedure‐related bleeding risk, endoscopists also need to consider the urgency of the endoscopic procedure, the thromboembolic risk of the patient if antithrombotic therapy is temporarily withheld, and the timing of discontinuation/resumption of antithrombotic therapy in the decision‐making process. Diagnostic endoscopic procedures with or without biopsy can often be done without interruption of antithrombotic therapy. If possible, elective procedures with high bleeding risk should be delayed in patients on antithrombotic therapy for conditions with high thrombotic risk. If high‐risk procedures cannot be delayed in these patients, thienopyridines, traditional and novel anticoagulants are usually withheld, whereas aspirin withdrawal is decided on a case by case basis. In patients with high thrombotic risk, communication with the prescribing clinician before proceeding to procedures with high bleeding risk is particularly important in optimizing the peri‐procedural management plan of antithrombotic therapy.     

The haemorrhagic and antithrombotic effects of dermatan sulphate

Heparin and dermatan sulphate are effective antithrombotic agents but the clinical use of heparin is complicated by haemorrhage. The haemorrhagic effect of dermatan sulphate is unknown. In this study we compared the antithrombotic, haemorrhagic and anticoagulant effects of heparin and dermatan sulphate in rabbits. The antithrombotic effect was measured as prevention of venous thrombus formation. The haemorrhagic effect was measured as 51Cr-blood loss from standardized cuts in rabbit ears. The anticoagulant effect was measured as changes in the APTT, TCT and circulating anti-factor Xa level, and the formation of 125I-thrombin/inhibitor complexes ex vivo. The effect of heparin and dermatan sulphate on collagen-induced platelet aggregation was measured ex vivo. Maximal antithrombotic effects of heparin and dermatan sulphate were achieved with 70 and 500 micrograms/kg respectively. A 20-fold increase in heparin dose caused an 8-fold increase in blood loss and higher doses (40- and 80-fold increases) caused further dose-related increases in blood loss (13- and 35-fold increases respectively). In contrast, a 20- to 40-fold increase in the antithrombotic dose of dermatan sulphate did not increase blood loss and an 80-fold dose increase caused only a 7-fold increase in blood loss. There was no relationship between the antithrombotic and haemorrhagic effects of either heparin or dermatan sulphate and their anticoagulant activities. In contrast, there was a relationship between the dose-related enhancement of blood loss by these glycosaminoglycans and the inhibition of collagen-induced platelet aggregation ex vivo. These results suggest that dermatan sulphate is less haemorrhagic than heparin at equivalent antithrombotic doses, and that the haemorrhagic effect is associated with a glycosaminoglycan-induced platelet defect.     

Antithrombotic therapy in atrial fibrillation and additional stroke/embolism risk factors. CORSurvey Study]

OBJECTIVES: To evaluate 1) how many patients with atrial fibrillation (AF) and heart failure were discharged from Austrian hospitals with antithrombotic therapy, 2) if the presence of risk factors for stroke/embolism (age > 65 years, arterial hypertension, diabetes, and previous stroke) influence the choice of antithrombotic therapy and if the presence of contraindications for oral anticoagulation (dementia, alcohol abuse) influence the choice of antithrombotic therapy, and 3) if there are differences among the types of departments in the use of antithrombotic therapy. PATIENTS: Included were 1566 patients (841 female, 725 male, mean age 76 years) with AF and heart failure. METHODS: At discharge, a questionnaire was completed including risk factors, contraindications for antithrombotic therapy, and antithrombotic medication. RESULTS: Oral anticoagulants (OAC) had 26% of the cases, acetyl salicylic acid (ASA) 31%, a combination of OAC and ASA 2%, and no antithrombotic therapy 41%. The risk factors age > 65 years, arterial hypertension, diabetes, and previous stroke did not influence the choice of antithrombotic therapy. Dementia but not alcohol abuse influenced the choice against OAC. The rate of OAC was higher in cardiological or cardiovascular rehabilitation clinics than in other departments. CONCLUSION: The results of this survey show that in medical practice the recommendations regarding antithrombotic therapy in atrial fibrillation are rarely considered, especially when additional risk factors are present.     

急性冠状动脉综合征合并房颤高龄患者抗栓治疗策略新进展

高龄老年急性冠脉综合征患者合并房颤比率高,面临缺血及出血双重高风险.针对该类人群的抗栓治疗方案,尚缺乏统一的共识.本文就目前急性冠脉综合征合并房颤高龄患者的抗栓治疗进行展综述.     

Antithrombotic treatment after coronary artery stenting in patients on chronic oral anticoagulation: an international survey of current clinical practice.

BACKGROUND: In the absence of evidence-based data, the optimal antithrombotic treatment after coronary artery stenting in patients on chronic oral anticoagulation (OAC) remains unknown. In order to investigate current practice in this setting, an international survey was carried out. METHODS: A questionnaire was e-mailed to 40 internationally renowned, foreign Interventional Centers worldwide. RESULTS: Out of the 24 Centers (60%) replying, only in 13 (54%) is antithrombotic treatment carried out in accordance with a standardized protocol. OAC is stopped in favor of aspirin plus ticlopidine/clopidogrel in selected (low thromboembolic risk) conditions in 13 (54%) Centers. When OAC is continued, the association with a single antiplatelet is employed in a few Centers only, as opposed to triple antithrombotic treatment (OAC and aspirin plus ticlopidine/clopidogrel) which is adopted, selectively or systematically, in the majority (83%) of Centers. In 8 (33%) Centers adopting triple antithrombotic treatment, the dose of OAC is decreased in all patients, whereas in 9 (38%) it is left unchanged. Upon completion of 1 to 3-6 months of antithrombotic treatment with OAC and single/dual antiplatelets, in 9 (38%) Centers this regimen is continued indefinitely, whereas in 10 (41%) antiplatelets are systematically withdrawn. Out of the 13 Centers, selectively exchanging OAC for aspirin plus ticlopidine/clopidogrel, low- or full-dose low-molecular-weight heparin is added in selected (high thromboembolic risk) cases in 3 (23%) and 5 (38%) Centers, respectively. Following 1 to 3-6 months of aspirin plus ticlopidine/clopidogrel antithrombotic treatment, OAC is resumed in all cases in 9 (69%) Centers and in no cases in 1 (8%). CONCLUSIONS: Our survey shows a high variability in the current antithrombotic treatment of patients on chronic OAC undergoing coronary artery stenting. Although various regimens may be adopted, the optimal antithrombotic treatment for this patient subset still needs to be identified.     

Antithrombotic and bleeding effects of glycosaminoglycans with different degrees of sulphation

We recently reported that the in vitro anticoagulant activities of dermatan sulphate and heparan sulphate were improved with increased sulphation. In this study we determined how the degree of sulphation of glycosaminoglycans influences their antithrombotic and bleeding effects in vivo. We compared the antithrombotic effects of each glycosaminoglycan by measuring their ability to inhibit experimentally-induced thrombus formation in rabbit jugular veins. The bleeding effect of each glycosaminoglycan was measured by comparing their ability to increase the amount of 51Cr-blood lost from five standardized cuts in rabbit ears. Increased sulphation only improved the antithrombotic effects of dermatan sulphate and heparan sulphate. In contrast, increased sulphation enhanced the blood loss associated with all the glycosaminoglycans evaluated. We conclude that the antithrombotic effects of heparan sulphate and dermatan sulphate can be enhanced by increased sulphation, but that the improved antithrombotic effects are compromised by the concomitant increase in bleeding side-effects.