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JAMA:双重抗血小板治疗仍为PCI后药物治疗基石

来源:JAMA 2013-07-12 18:42

美国一项综述表明,双重抗血小板治疗仍为经皮冠脉介入(PCI)后药物治疗的基石。论文7月10日在线发表于《美国医学会杂志》(JAMA)。

研究者对PubMed和Cochrane数据库进行了检索,并纳入PCI后药物治疗的相关文献。大型随机对照试验、系统综述和meta分析被列为首选。共有91项研究符合纳入标准。

结果显示,阿司匹林和P2Y12抑制剂(即噻氯匹定、氯吡格雷、普拉格雷和替格瑞洛)双重抗血小板治疗可降低PCI后支架血栓形成和后续心血管事件风险,并且为当前的标准治疗方案。阿司匹林应持续应用,并且小剂量(75-100 mg/d)优于大剂量。P2Y12抑制剂应在PCI后应用12个月,除非患者有较高的出血风险;但目前亦有研究正在评估更长期或更短期治疗的价值。

在急性冠脉综合征患者中,与氯吡格雷相比,普拉格雷和替格瑞洛可进一步减少心血管缺血性事件,但与出血风险升高相关。在可能情况下,非心脏手术应延迟至冠脉支架置入12个月后实施。

冠脉支架置入后应用华法林的患者如同时接受双重抗血小板治疗则出血风险高,这样的患者停用阿司匹林可能有益。

目前不推荐常规进行血小板功能检测或基因监测。(生物谷Bioon.com)             

生物谷推荐英文摘要:

JAMA                   doi:10.1001/jama.2013.7086


Medical Management After Coronary Stent Implantation: A Review

Emmanouil S. Brilakis, MD, PhD; Vishal G. Patel, MD; Subhash Banerjee, MD

Importance  Percutaneous coronary intervention (PCI) with stents is currently the most commonly performed coronary revascularization procedure; hence, optimizing post-PCI outcomes is important for all physicians treating such patients.

Objective  To review the contemporary literature on optimal medical therapy after PCI.

Evidence Review  We performed a comprehensive search of the PubMed and Cochrane Library databases for manuscripts on medical therapy after PCI, published between 2000 and February 2013. Bibliographies of the retrieved studies were searched by hand for other relevant studies. Priority was given to data from large randomized controlled trials, systematic reviews, and meta-analyses. Of the 6852 publications retrieved, 91 were included.

Findings  Dual antiplatelet therapy with aspirin and a P2Y12 inhibitor (eg, ticlopidine, clopidogrel, prasugrel, ticagrelor) reduces the risk of stent thrombosis and subsequent cardiovascular events post-PCI (number needed to treat, 33-53) and is the current standard of care. Aspirin should be continued indefinitely and low dose (75-100 mg daily) is preferred over higher doses. A P2Y12 inhibitor should be administered for 12 months after PCI, unless the patient is at high risk for bleeding; however, ongoing studies are assessing the value of shorter or longer duration of P2Y12 inhibitor administration. In patients with acute coronary syndromes, prasugrel and ticagrelor further reduce cardiovascular ischemic events compared with clopidogrel but are associated with higher bleeding risk. If possible, noncardiac surgery should be delayed until 12 months after coronary stenting. Patients receiving coronary stents who require warfarin are at high risk for bleeding if they also receive dual antiplatelet therapy. Omission of aspirin may be advantageous in such patients. Routine platelet function or genetic testing is currently not recommended to tailor antiplatelet therapy after PCI.

Conclusions and Relevance  Dual antiplatelet therapy remains the cornerstone of medical therapy after PCI. Continuous advances in pharmacotherapy can further enhance our capacity to improve outcomes in this high-risk patient group.

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