Department of Cardiology, J. Dietl Hospital, Kraków, Poland.
Kardiol Pol. 2009 Dec;67(12):1335-41.
Dual antiplatelet therapy for 12 months is currently recommended for all patients with acute coronary syndrome (ACS), both for those treated pharmacologically or with percutaneous coronary interventions (PCI). Recently, the need for simultaneous administration of dual antiplatelet and oral anticoagulant therapy (triple therapy) has become more common. However, in addition to intensifying antiplatelet treatment, the risk of haemorrhagic complications is also significantly increased with triple therapy.
To assess the in-hospital use of triple therapy in patients with ACS, who have indications for long-term anticoagulation, and to define the reasons for not administering such a therapy.
The analysis included 298 patients diagnosed with ACS who were admitted to our department. Analysis of recommended treatment was conducted upon discharge from hospital after ACS and during hospitalisation. The reason for discontinuation or non-compliance with oral anticoagulant (OAC) therapy was also assessed.
Out of 298 patients diagnosed with ACS, 53 (17.8%) had indications for long-term anticoagulation. The largest group consisted of patients with unstable angina who were treated pharmacologically (51.7%). The most common indication for chronic anticoagulation was paroxysmal atrial fibrillation (AF) (62%). At discharge from hospital, only 15.1% of patients received triple therapy. There was no significant association between the mode of treatment (triple therapy vs. lack of it) and indication for antiplatelet treatment (p = 0.18) or anticoagulation (p = 0.27). Among risk factors for bleeding, only prior episode of bleeding [p = 0.0002; odds ratio (OR) 4.17] and treatment with PCI (p = 0.02; OR impossible to assess because of too small group) were significantly associated with withdrawal of triple therapy.
The use of triple therapy in patients presenting with ACS and indications for long-term anticoagulation is insufficient. The reasons for not prescribing triple therapy are not clear. One explanation could be excessive concerns about haemorrhagic complications. There is a lack of equivocal guidelines and large randomised trials which would clearly define the optimal management strategy for patients presenting with ACS and indications for long-term anticoagulation therapy.
目前建议所有急性冠状动脉综合征（ACS）患者，包括接受药物治疗或经皮冠状动脉介入治疗（PCI）的患者，接受 12 个月的双联抗血小板治疗。最近，同时使用双联抗血小板和口服抗凝剂治疗（三联治疗）的需求变得更加普遍。然而，三联治疗除了强化抗血小板治疗外，还会显著增加出血并发症的风险。
评估 ACS 患者中需要长期抗凝治疗且有指征进行三联治疗的患者住院期间使用三联治疗的情况，并确定未进行三联治疗的原因。
分析纳入了 298 例因 ACS 入院的患者。在 ACS 出院后和住院期间，对推荐的治疗方案进行分析。还评估了停用或不遵守口服抗凝剂（OAC）治疗的原因。
在 298 例 ACS 患者中，53 例（17.8%）有长期抗凝指征。最大的一组患者为接受药物治疗的不稳定型心绞痛患者（51.7%）。慢性抗凝的最常见指征是阵发性心房颤动（AF）（62%）。出院时，仅有 15.1%的患者接受了三联治疗。治疗方式（三联治疗与无三联治疗）与抗血小板治疗指征（p=0.18）或抗凝指征（p=0.27）之间无显著相关性。在出血的危险因素中，只有既往出血史（p=0.0002；比值比[OR]4.17）和接受 PCI 治疗（p=0.02；OR 无法评估，因为组太小）与三联治疗的停药显著相关。
ACS 合并有长期抗凝指征的患者中，三联治疗的使用率不足。不进行三联治疗的原因尚不清楚。一种解释可能是过度担心出血并发症。目前缺乏明确的指南和大型随机试验，无法清楚地定义 ACS 合并有长期抗凝治疗指征患者的最佳管理策略。
