Rossini Roberta, Musumeci Giuseppe, Lettieri Corrado, Molfese Maria, Mihalcsik Laurian, Mantovani Paola, Sirbu Vasile, Bass Theodore A, Della Rovere Francesco, Gavazzi Antonello, Angiolillo Dominick J
Divisione di Cardiologia, Dipartimento Cardiovascolare, Ospedali Riuniti di Bergamo, Bergamo, Italy.
Am J Cardiol. 2008 Dec 15;102(12):1618-23. doi: 10.1016/j.amjcard.2008.08.021. Epub 2008 Sep 24.
In patients undergoing coronary stenting, long-term dual antiplatelet therapy with aspirin and clopidogrel reduces atherothrombotic events but also increases the risk of bleeding. The potential for developing bleeding complications is further enhanced in patients also requiring oral anticoagulant treatment ("triple therapy"). The aim of the study is to assess long-term outcomes associated with the use of triple-therapy in patients undergoing coronary stenting and evaluate how these may be affected by targeting international normalized ratio (INR) values to the lower therapeutic range. We prospectively studied 102 consecutive patients undergoing coronary stenting treated with dual antiplatelet therapy also requiring oral anticoagulation. INR was targeted to the lower therapeutic range (2.0 to 2.5). Patients requiring oral anticoagulant therapy because of mechanical valve prosthesis were excluded. Patients were followed for 18 months, and bleeding, defined according to Thrombolysis in Myocardial Infarction criteria, and major adverse cardiac events were recorded. Outcomes were compared with a control group (n = 102) treated only with dual antiplatelet therapy. The mean duration of triple therapy was 157 +/- 134 days. At 18 months, a nonsignificant increase in bleeding was observed in the triple versus dual therapy group (10.8% vs 4.9%, p = 0.1). INR values were higher in patients with bleeding (2.8 +/- 1.1 vs 2.3 +/- 0.2, p = 0.0001). In patients who had INR values within the recommended target (79.4%), the risk of bleeding was significantly lower compared with patients who did not (4.9 vs 33%, p = 0.00019) and with that observed in the control group (4.9%). An INR >2.6 was the only independent predictor of bleeding. There were no significant differences in major adverse cardiac events between groups (5.8% vs 4.9%, p = 0.7). In conclusion, in patients undergoing coronary stenting on triple therapy, targeting lower therapeutic INR values reduces the risk of bleeding complications.
在接受冠状动脉支架置入术的患者中，阿司匹林和氯吡格雷联合进行长期双重抗血小板治疗可减少动脉粥样硬化血栓形成事件，但也会增加出血风险。对于还需要口服抗凝治疗（“三联疗法”）的患者，发生出血并发症的可能性会进一步增加。本研究的目的是评估冠状动脉支架置入术患者使用三联疗法的长期预后，并评估将国际标准化比值（INR）值设定在较低治疗范围内如何影响这些预后。我们前瞻性地研究了102例连续接受双重抗血小板治疗且还需要口服抗凝治疗的冠状动脉支架置入术患者。将INR设定在较低治疗范围（2.0至2.5）。因机械瓣膜假体而需要口服抗凝治疗的患者被排除在外。对患者进行了18个月的随访，并记录了根据心肌梗死溶栓标准定义的出血情况以及主要不良心脏事件。将结果与仅接受双重抗血小板治疗的对照组（n = 102）进行比较。三联疗法的平均持续时间为157±134天。在18个月时，三联疗法组与双重疗法组相比，出血有非显著性增加（10.8%对4.9%，p = 0.1）。出血患者的INR值更高（2.8±1.1对2.3±0.2，p = 0.0001）。INR值在推荐目标范围内的患者（79.4%），其出血风险与未在该范围内的患者相比显著更低（4.9%对33%，p = 0.00019），且与对照组中观察到的出血风险（4.9%）相比也更低。INR>2.6是出血的唯一独立预测因素。两组之间主要不良心脏事件无显著差异（5.8%对4.9%，p = 0.7）。总之，在接受三联疗法的冠状动脉支架置入术患者中，将治疗性INR值设定在较低水平可降低出血并发症的风险。
