Fitchett David, Goodman Shaun G, Gupta Milan, Langer Anatoly
St Michael's Hospital, Toronto, Canada.
Can J Cardiol. 2002 Nov;18(11):1179-90.
Non-ST segment elevation acute coronary syndrome (NSTE ACS) has a high rate of recurrence. Both antithrombotic and antiplatelet agents in association with coronary revascularization play an important role in the prevention of an adverse outcome. Acetylsalicylic acid, heparin and low molecular weight heparin (especially enoxaparin), and the intravenous small-molecule glycoprotein IIb/IIIa inhibitors, are of proven value. Recently, clopidogrel has been shown to reduce recurrent ischemic events, both early and during the first year after the index ACS. Furthermore, two recent trials have shown that an early invasive strategy is preferable to a conservative approach in the higher risk patient. As yet, no study has shown either the efficacy or the safety of combining all these treatment modalities in the management of the NSTE ACS patient. The initial choice of antithrombotic and antiplatelet agents and a strategy for early revascularization is made after considering the risk of recurrent acute ischemic events. For patients destined to have an early invasive strategy, it is desirable to choose an anti-thrombotic/antiplatelet combination that will reduce events before revascularization, enhance the revascularization procedure and not be associated with excessive bleeding. A risk-determined algorithm is presented, which applies observations made at the time of presentation to decide the optimal management for the individual patient.
非ST段抬高型急性冠状动脉综合征（NSTE ACS）复发率很高。抗栓和抗血小板药物与冠状动脉血运重建联合应用在预防不良结局方面发挥着重要作用。乙酰水杨酸、肝素和低分子肝素（尤其是依诺肝素）以及静脉注射小分子糖蛋白IIb/IIIa抑制剂已被证明具有价值。最近，氯吡格雷已被证明可减少早期及首次急性冠状动脉综合征（ACS）后第一年的复发性缺血事件。此外，最近的两项试验表明，在高危患者中，早期侵入性策略优于保守方法。然而，尚无研究表明在NSTE ACS患者的治疗中联合使用所有这些治疗方式的疗效或安全性。在考虑复发性急性缺血事件的风险后，做出抗栓和抗血小板药物的初始选择以及早期血运重建策略。对于注定要采用早期侵入性策略的患者，理想的做法是选择一种抗栓/抗血小板联合用药，该联合用药可在血运重建前减少事件发生、增强血运重建过程且不伴有过多出血。本文提出了一种风险决定算法，该算法应用就诊时的观察结果来为个体患者确定最佳治疗方案。
