Spinler Sarah A
Department of Pharmacy Practice/Pharmacy Administration, University of the Sciences in Philadelphia, 600 S 43rd St, Box GRI 108-T, Philadelphia, PA 19104, USA.
Am J Manag Care. 2009 Mar;15(2 Suppl):S42-7.
Percutaneous coronary intervention (PCI) with stenting is increasingly being utilized for acute coronary syndromes (ACS), and the debate over the safety and efficacy of drug-eluting stents (DESs) versus bare-metal stents (BMSs) has intensified. The difficulty in consistently assessing stent safety is because of the widespread off-label use in patients with clinical features and coronary anatomy inconsistent with the approved use in stable patients with relatively noncomplex coronary stenosis, short-term follow-up of only 1 year in pivotal clinical trials that leads to approval, and inconsistency in the nature and duration of adjunctive antiplatelet therapy. Of concern are the high recurrence rates after the first episode of stent thrombosis, as demonstrated by the Dutch Stent Thrombosis Study. However, more recent analyses using better statistical models favor DESs versus BMSs, both for survival and repeat revascularizations. Recommendations from updated guidelines from the American College of Cardiology/American Heart Association/Society for Cardiovascular Angiography and Interventions are summarized for oral antiplatelet therapy with DESs and BMSs in the management of ACS. For patients undergoing elective PCI, dual antiplatelet therapy with aspirin and clopidogrel is recommended for at least 4 weeks for a BMS and 12 months for a DES, with aspirin continued indefinitely. For patients with non-ST-segment elevation ACS or ST-segment elevation myocardial infarction, dual antiplatelet therapy is recommended for at least 12 months. In summary, more recent data suggest that the benefits outweigh the risks of DESs compared with BMSs, and that the rate of DES placement will continue to rise. It is important that clinicians be aware of the indications for dual antiplatelet therapy and the appropriate durations of dual antiplatelet therapy in patients undergoing PCI.
经皮冠状动脉介入治疗（PCI）并植入支架越来越多地用于急性冠状动脉综合征（ACS），药物洗脱支架（DES）与裸金属支架（BMS）在安全性和有效性方面的争论也日益激烈。持续评估支架安全性存在困难，原因在于其在临床特征和冠状动脉解剖结构与批准用于相对不复杂冠状动脉狭窄的稳定患者不一致的患者中广泛存在的标签外使用情况、关键临床试验中仅1年的短期随访（这导致了支架的获批）以及辅助抗血小板治疗的性质和持续时间不一致。荷兰支架血栓形成研究表明，首次发生支架血栓形成后的高复发率令人担忧。然而，使用更好统计模型的最新分析表明，无论是在生存率还是再次血运重建方面，DES都优于BMS。总结了美国心脏病学会/美国心脏协会/心血管造影和介入学会最新指南中关于DES和BMS在ACS管理中口服抗血小板治疗的建议。对于接受择期PCI的患者，建议使用阿司匹林和氯吡格雷进行双联抗血小板治疗，BMS至少持续4周，DES至少持续12个月，阿司匹林需无限期持续使用。对于非ST段抬高型ACS或ST段抬高型心肌梗死患者，建议双联抗血小板治疗至少持续12个月。总之，最新数据表明，与BMS相比，DES的获益大于风险，DES的植入率将继续上升。临床医生了解PCI患者双联抗血小板治疗的适应证以及适当的治疗持续时间非常重要。
