IIS Aragón, Servicio de Aparato Digestivo, Hospital Clínico Universitario Lozano Blesa, Zaragoza, Spain.
Drugs. 2011 Jan 1;71(1):1-10. doi: 10.2165/11585320-000000000-00000.
Patients taking low-dose aspirin for cardiovascular prevention who develop an acute peptic ulcer bleeding event represent a serious challenge in clinical practice. Aspirin discontinuation is associated with increased risk of developing a new cardiovascular event, but there is little evidence on the outcomes and best management strategy in the setting of an acute ulcer bleeding event. In this clinical scenario, it is common clinical practice to interrupt aspirin treatment for various, sometimes long, periods of time. A recent study suggests that patients with bleeding ulcers who keep taking aspirin after successful endoscopic therapy followed by high-dose intravenous pantoprazole, bolus of 80 mg followed by 8 mg/h for 3 days, have a small increase in the risk of rebleeding but a lower overall and cardiovascular 30-day mortality rate than those who stop taking aspirin treatment. Based on current, although limited, data, we propose that these patients should undergo early endoscopic therapy to control bleeding followed by a high-dose intravenous PPI, with early reintroduction of aspirin treatment within a 5-day window after the last dose. However, in patients taking aspirin for the primary prevention of cardiovascular events, it seems reasonable to stop aspirin treatment, re-evaluate the indication and, if needed, reintroduce aspirin after the risk of ulcer rebleeding decreases, usually after hospital discharge. In the presence of an acute ulcer bleeding event soon after the placement of coronary stents, the risk of stent thrombosis with removal of antiplatelet therapy is very high. We believe that early therapeutic endoscopy and a high-dose intravenous PPI is advisable in order to maintain patients on dual antiplatelet therapy. Until more evidence becomes available, clinicians will have to rely on actual data and the use of common sense to select the best option for the patient.
正在服用低剂量阿司匹林进行心血管预防的患者如果发生急性消化性溃疡出血事件，这在临床实践中是一个严峻的挑战。阿司匹林停药与新发心血管事件风险增加相关，但在急性溃疡出血事件背景下，关于结局和最佳管理策略的证据很少。在这种临床情况下，中断阿司匹林治疗是常见的临床实践，有时会中断很长时间。最近的一项研究表明，在成功进行内镜治疗和随后接受高剂量静脉注射泮托拉唑（首剂 80mg，继以 8mg/h，持续 3 天）后继续服用阿司匹林的出血性溃疡患者，再次出血的风险略有增加，但总体和心血管 30 天死亡率低于停药的患者。基于目前虽然有限的数据，我们建议这些患者应进行早期内镜治疗以控制出血，然后给予高剂量静脉 PPI，并在最后一剂后 5 天内尽早重新开始阿司匹林治疗。然而，对于因心血管事件一级预防而服用阿司匹林的患者，似乎合理的做法是停止阿司匹林治疗，重新评估适应证，如果需要，在溃疡再出血风险降低后重新开始服用阿司匹林，通常在出院后。在冠状动脉支架置入后不久发生急性溃疡出血事件时，停用抗血小板治疗会导致支架血栓形成的风险非常高。我们认为，为了维持双联抗血小板治疗，早期进行治疗性内镜检查和给予高剂量静脉 PPI 是明智的。在更多证据出现之前，临床医生将不得不依赖实际数据和运用常识为患者选择最佳方案。
