Department of Cardiology, Leiden University Medical Centre, Leiden, The Netherlands.
Curr Med Res Opin. 2012 Feb;28(2):203-11. doi: 10.1185/03007995.2011.651526. Epub 2012 Jan 19.
Despite revascularisation, outcomes among patients presenting with ST-elevation myocardial infarction (STEMI) remain suboptimal.
This review compares clopidogrel, ticagrelor and prasugrel as antiplatelet strategies with a particular focus on STEMI. Medline and Google Scholar were searched for relevant terms and citations from these articles were also assessed.
While clopidogrel represented an important therapeutic advance, variations in platelet response and a relatively slow onset of action compromise outcomes in some patients. Ticagrelor and prasugrel are more effective than clopidogrel, although essentially only one large study supports each drug. Nevertheless, a detailed examination of the evidence reveals several issues that may influence the decision to prescribe ticagrelor instead of prasugrel and vice versa. Arguably, prasugrel could be the preferred strategy in STEMI, reflecting the drugs' efficacy in clopidogrel-naïve patients, the most common group in clinical practice. Conversely, ticagrelor may be a better option than clopidogrel in clopidogrel-pretreated patients showing a mortality benefit irrespective of clopidogrel pre-treatment. The clinical benefits offered by prasugrel and ticagrelor need to be offset against the increased cost and we suggest an algorithm for using these new compounds in the primary percutaneous coronary intervention (PCI) setting. The risk of bleeding associated with prasugrel is similar to that of clopidogrel and ticagrelor following exclusion of at-risk patients. Nevertheless, prasugrel may be especially appropriate for STEMI patients undergoing PCI who are considered to be at high risk of ischaemia. Conversely, ticagrelor's short half-life, while potentially a limitation during maintenance therapy, may reduce bleeding risk if the patient undergoes CABG during the same hospital admission, although confirmatory studies are needed.
Future studies also need to address several other outstanding issues, such as the subsequent approach if patients do not undergo PCI, and to overcome limitations in and differences between the primary studies. In particular, head-to-head comparisons need to compare directly the risks and benefits of ticagrelor and prasugrel in STEMI patients. These caveats notwithstanding, ticagrelor and prasugrel markedly improve the prognosis for patients with STEMI.
尽管进行了血运重建，但 ST 段抬高型心肌梗死（STEMI）患者的预后仍然不理想。
本文综述了氯吡格雷、替格瑞洛和普拉格雷这三种抗血小板策略，特别关注了 STEMI。检索了 Medline 和 Google Scholar 中相关的术语，并评估了这些文章的参考文献。
虽然氯吡格雷是一项重要的治疗进展，但血小板反应的变异性和相对较慢的作用开始时间会使某些患者的结局恶化。替格瑞洛和普拉格雷比氯吡格雷更有效，尽管实际上只有一项大型研究支持每种药物。然而，对证据的详细检查揭示了一些可能影响决定开替格瑞洛而不是普拉格雷的因素，反之亦然。可以说，普拉格雷可能是 STEMI 的首选策略，反映了药物在临床上最常见的氯吡格雷初治患者中的疗效。相反，对于氯吡格雷预处理的患者，无论氯吡格雷预处理如何，替格瑞洛都可能比氯吡格雷更有优势，这些患者显示出死亡率获益。需要权衡普拉格雷和替格瑞洛带来的临床获益与增加的成本，我们建议在直接经皮冠状动脉介入治疗（PCI）中使用这些新化合物的算法。排除高危患者后，普拉格雷相关出血风险与氯吡格雷和替格瑞洛相似。然而，普拉格雷可能特别适合接受 PCI 的 STEMI 患者，这些患者被认为存在缺血高风险。相反，替格瑞洛的半衰期较短，尽管在维持治疗期间可能是一个限制，但如果患者在同一住院期间接受冠状动脉旁路移植术（CABG），可能会降低出血风险，尽管需要确认性研究。
未来的研究还需要解决其他一些未决问题，例如如果患者不接受 PCI 后的后续治疗方法，以及克服主要研究中的局限性和差异。特别是，需要直接比较替格瑞洛和普拉格雷在 STEMI 患者中的风险和获益。尽管存在这些警告，但替格瑞洛和普拉格雷明显改善了 STEMI 患者的预后。
