Rao Sunil V, Eikelboom John A, Granger Christopher B, Harrington Robert A, Califf Robert M, Bassand Jean-Pierre
The Duke Clinical Research Institute, Durham, NC, USA.
Eur Heart J. 2007 May;28(10):1193-204. doi: 10.1093/eurheartj/ehm019. Epub 2007 Apr 24.
Antithrombotic therapy and invasive risk stratification in selected high-risk patients have improved outcomes from non-ST-segment elevation acute coronary syndromes (NSTE-ACS), but carry a risk of bleeding and blood transfusion. Although the true incidence of bleeding depends on the population studied (i.e. clinical trial vs. registry), the definition used, and the use of invasive procedures, it is becoming clear that bleeding is associated with an increased risk for adverse outcomes including myocardial infarction and death. Blood transfusion itself may carry a risk for ischaemic outcomes that is independent of bleeding. Therefore, therapies that provide an adequate level of anticoagulation to reduce ischaemia while simultaneously minimizing the risk of bleeding and transfusion have the potential to improve outcomes among patients with NSTE-ACS. Anticoagulants studied in recent clinical trials that have focused on bleeding reduction include fondaparinux and bivalirudin. In this review, we discuss the clinical trial evidence for these agents, the association between bleeding and clinical outcomes, the biology of blood transfusion and potential mechanisms underlying its association with adverse outcomes, and propose strategies to deal with bleeding complications. Future directions for research and clinical practice are also discussed.
在特定高危患者中，抗栓治疗和侵入性风险分层改善了非ST段抬高型急性冠状动脉综合征（NSTE-ACS）的预后，但存在出血和输血风险。尽管出血的真实发生率取决于所研究的人群（即临床试验与注册研究）、所使用的定义以及侵入性操作的使用情况，但越来越清楚的是，出血与包括心肌梗死和死亡在内的不良结局风险增加相关。输血本身可能带来与出血无关的缺血性结局风险。因此，能够提供足够抗凝水平以减少缺血同时将出血和输血风险降至最低的治疗方法，有可能改善NSTE-ACS患者的预后。近期专注于减少出血的临床试验中研究的抗凝剂包括磺达肝癸钠和比伐卢定。在本综述中，我们讨论了这些药物的临床试验证据、出血与临床结局之间的关联、输血生物学及其与不良结局关联的潜在机制，并提出了处理出血并发症的策略。还讨论了未来的研究和临床实践方向。
