Faxon David P
Section of Cardiology, University of Chicago, Chicago, Illinois, USA.
Rev Cardiovasc Med. 2005;6 Suppl 4:S3-14.
Thrombosis superimposed on arteriosclerosis is the principal cause of mortality and morbidity in patients with arteriosclerosis. The use of antiplatelet agents and anticoagulants in the treatment of arteriosclerosis is well established, based on many large randomized trials. Aspirin is indicated for primary prevention in patients at increased risk of developing symptomatic atherosclerotic vascular disease. For patients with known vascular disease, antiplatelet therapy with aspirin is a well-established treatment. For high-risk patients such as those with acute coronary syndromes (ACS; unstable angina, myocardial infarction), dual antiplatelet therapy with aspirin and clopidogrel is indicated, based on results of the Clopidogrel in Unstable Angina to Prevent Recurrent Events (CURE) trial. Platelet glycoprotein IIb/IIIa agents are powerful inhibitors of platelet function and are also effective in ACS, but the benefit is confined to high-risk patients. Anticoagulation with heparin or low-molecular-weight heparin (eg, enoxaparin) is also effective, with an approximately 50% reduction in cardiovascular events. These agents are also indicated for patients undergoing percutaneous coronary intervention. Prolonged dual antiplatelet therapy (at least 6 months) is recommended for patients receiving drug-eluting stents. The efficacy of antiplatelet therapy is thus well established in treating atherothrombosis, but aggressive therapy is associated with an increased bleeding risk. Newer agents may provide improved efficacy with a lower risk of bleeding.
动脉硬化叠加血栓形成是动脉硬化患者死亡和发病的主要原因。基于许多大型随机试验，抗血小板药物和抗凝剂在动脉硬化治疗中的应用已得到充分确立。阿司匹林适用于有发生症状性动脉粥样硬化性血管疾病风险增加的患者的一级预防。对于已知患有血管疾病的患者，使用阿司匹林进行抗血小板治疗是一种公认的疗法。对于高危患者，如急性冠状动脉综合征（ACS；不稳定型心绞痛、心肌梗死）患者，根据“氯吡格雷用于不稳定型心绞痛预防再发事件”（CURE）试验的结果，建议使用阿司匹林和氯吡格雷进行双重抗血小板治疗。血小板糖蛋白IIb/IIIa制剂是强大的血小板功能抑制剂，在ACS中也有效，但益处仅限于高危患者。使用肝素或低分子肝素（如依诺肝素）进行抗凝也有效，可使心血管事件减少约50%。这些药物也适用于接受经皮冠状动脉介入治疗的患者。对于接受药物洗脱支架的患者，建议延长双重抗血小板治疗（至少6个月）。因此，抗血小板治疗在治疗动脉粥样硬化血栓形成方面的疗效已得到充分确立，但积极治疗会增加出血风险。新型药物可能在降低出血风险的同时提供更好的疗效。
