Flaker Greg, Weachter Richard
Division of Cardiovascular Medicine, University of Missouri-Columbia, Five Hospital Drive, CE306, Columbia, MO, 65212, USA,
Curr Treat Options Cardiovasc Med. 2011 Oct;13(5):361-9. doi: 10.1007/s11936-011-0139-4.
Stroke is a dreaded complication of atrial fibrillation. In the past, preventive therapy included aspirin and oral anticoagulation. Selected patients who are not suitable for oral anticoagulation may benefit from the addition of clopidogrel with aspirin. This combination, when compared with aspirin, offers a reduced risk of stroke at a cost of more major bleeding. We use this therapy in patients with atrial fibrillation who have unstable coronary syndromes or in patients who receive coronary artery stents who are not good candidates for "triple therapy" with aspirin, clopidogrel, and warfarin. The duration of therapy is tempered by many variables. In the case of coronary stents, we ask the interventionalist to consider a bare metal stent to shorten the duration of need for clopidogrel plus aspirin. After several months of combination therapy, we stop this therapy and begin warfarin therapy. Dabigatran is commercially available in the United States. In patients who have difficult to control International Normalized Ratio (INR) values or who do not wish to have regular coagulation monitoring, dabigatran offers a huge advantage. The benefit seems less if the INR is consistently within range. We are impressed with the superior reduction in stroke and systemic embolism with 150 mg of dabigatran twice daily compared to warfarin and also its low risk of intracranial hemorrhage. The results of clinical trials involving factor Xa agents are now being presented. How these agents fit into the marketplace remains to be seen but they will offer clinicians additional therapy for stroke prevention in atrial fibrillation.
中风是心房颤动可怕的并发症。过去，预防性治疗包括阿司匹林和口服抗凝药。部分不适合口服抗凝治疗的患者加用氯吡格雷和阿司匹林可能会受益。与阿司匹林相比，这种联合用药可降低中风风险，但代价是大出血风险增加。我们在患有不稳定型冠状动脉综合征的心房颤动患者或接受冠状动脉支架置入术但不适合接受阿司匹林、氯吡格雷和华法林“三联疗法”的患者中使用这种治疗方法。治疗持续时间受多种因素影响。对于冠状动脉支架置入术患者，我们会请介入专家考虑使用裸金属支架，以缩短氯吡格雷加阿司匹林的使用时间。联合治疗数月后，我们会停止这种治疗并开始华法林治疗。达比加群在美国已上市。对于国际标准化比值（INR）值难以控制或不希望定期进行凝血监测的患者，达比加群具有很大优势。如果INR始终在正常范围内，其益处似乎就没那么大了。与华法林相比，每日两次服用150毫克达比加群在降低中风和全身性栓塞方面效果更佳，且颅内出血风险较低，给我们留下了深刻印象。目前正在公布涉及Xa因子药物的临床试验结果。这些药物如何进入市场还有待观察，但它们将为临床医生提供更多预防心房颤动中风的治疗方法。
