Bureau 236, Inserm 937, institut de cardiologie, hôpital Pitié-Salpêtrière (AP-HP), 47, boulevard de l'Hôpital, 75013 Paris, France.
Arch Cardiovasc Dis. 2009 Oct;102(10):697-710. doi: 10.1016/j.acvd.2009.08.009. Epub 2009 Oct 27.
Concern about procedure-related bleeding is a major reason for premature discontinuation of dual oral antiplatelet therapy (APT); treatment cessation is detrimental in patients with coronary artery disease (CAD), especially after drug-eluting stent (DES) placement. The nationwide REGINA survey was designed to evaluate how the interruption of dual APT is managed in the 'real world'.
Physicians (2700/4581) were randomly selected to participate in a computer-assisted telephone interview. Knowledge about DES and APT was appraised by multiple-choice questions. Strategies for temporary interruption of dual APT before an invasive or surgical procedure were evaluated using 21 scenarios, including high-risk (30 days after DES) and low-risk (18 months after DES) periods.
Out of 2700 practitioners, 2515 completed the interview. Rates of correct answers to basic knowledge questions ranged from 0% (dentists) to 52% (cardiologists). Unjustified total interruption of dual APT was much more frequent than expected (22.0% vs. 11.8%). A strategy of total interruption was less frequently chosen in the period of high ischemic risk compared to the low-risk period (13.7% vs. 31.1%, p<0.0001). Dual APT interruption in patients who require additional invasive cardiac or surgical procedures depended on type of physician consulted (more frequent in specialists than general practitioners or dentists), and on the physician's age and practice type (rural/private vs. urban/hospital). Correct answers were more frequently given in situations bearing a major risk, either ischemic or bleeding risk, than in those with no risk (49.2% vs. 30.2%, p<0.0001). Low-molecular-weight heparin was the substitution therapy in over two-thirds of scenarios and was associated with longer periods of APT interruption.
Adequate management of APT in patients with intracoronary stents who undergo potentially haemorrhagic invasive procedures depends mainly on the type of physician involved and their practice rather than on a carefully weighted assessment of ischemic/bleeding risk. Our findings suggest a lack of scientific evidence, insufficient knowledge of guidelines, and poor communication between physicians managing these patients.
担心与手术相关的出血是过早停止双联口服抗血小板治疗（DAPT）的主要原因；对于患有冠状动脉疾病（CAD）的患者，特别是在放置药物洗脱支架（DES）后，停止治疗是有害的。全国范围的 REGINA 调查旨在评估在“真实世界”中如何管理 DAPT 的中断。
随机选择医生（2700/4581 名）参与计算机辅助电话访谈。通过多项选择题评估对 DES 和 DAPT 的了解程度。通过 21 种情况评估在侵入性或手术前临时中断 DAPT 的策略，包括高风险（DES 后 30 天）和低风险（DES 后 18 个月）期。
在 2700 名从业者中，有 2515 人完成了访谈。对基础知识问题的正确答案率从 0%（牙医）到 52%（心脏病专家）不等。不合理的完全中断 DAPT 的情况比预期的更为常见（22.0%比 11.8%）。与低风险期相比，在高缺血风险期，选择完全中断 DAPT 的策略要少得多（13.7%比 31.1%，p<0.0001）。需要额外的侵入性心脏或手术程序的患者的 DAPT 中断取决于咨询的医生类型（专家比全科医生或牙医更频繁），以及医生的年龄和实践类型（农村/私人比城市/医院）。在有重大风险（无论是缺血风险还是出血风险）的情况下，回答更正确，而在没有风险的情况下，回答更正确（49.2%比 30.2%，p<0.0001）。超过三分之二的情况下使用低分子量肝素作为替代治疗，与 DAPT 中断时间较长有关。
在接受潜在出血性侵入性手术的冠状动脉支架内患者中，适当的 DAPT 管理主要取决于涉及的医生类型及其实践，而不是对缺血/出血风险的仔细加权评估。我们的发现表明缺乏科学证据、对指南的了解不足以及管理这些患者的医生之间沟通不畅。
