Iqbal Zafar, Rana Gurinder, Cohen Marc
Division of Cardiology, Newark Beth Israel Medical Center, Newark, NJ 07112, USA.
Curr Cardiol Rev. 2012 Aug;8(3):181-91. doi: 10.2174/157340312803217175.
Managing coronary thrombus is a challenging task and requires adequate knowledge of the various antithrombotic agents available. In this article, we will briefly analyze the risk-benefit profile of antithrombotic agents, with critical analysis of the scientific evidence available to support their use. Since thrombus consists of platelets and coagulation cofactors, an effective antithrombotic strategy involves using one anticoagulant with two or more antiplatelet agents. Unfractionated heparin traditionally has been the most commonly used anticoagulant but is fast being replaced by relatively newer agents like LMWH, direct thrombin inhibitors, and Factor Xa inhibitors. In recent years, the antiplatelet landscape has changed significantly with the availability of more potent and rapidly acting agents, like prasugrel and ticagrelor. These agents have demonstrated a sizeable reduction in ischemic outcomes in patients with ACS, who are treated invasively or otherwise, with some concern for an increased bleeding risk. Glycoprotein IIb/IIIa inhibitors have an established role in high risk NSTE ACS patients pretreated with dual antiplatelets, but its role in STEMI patients, treated with invasive approach and dual antiplatelets, has not been supported consistently across the studies. Additionally, in recent years, its place as a directly injected therapy into coronaries has been looked into with mixed results. In conclusion, a well-tailored antithrombotic strategy requires taking into account each patient's individual risk factors and clinical presentation, with an effort to strike balance between not only preventing ischemic outcomes but also reducing bleeding complications.
处理冠状动脉血栓是一项具有挑战性的任务，需要对现有的各种抗血栓药物有充分的了解。在本文中，我们将简要分析抗血栓药物的风险效益概况，并对支持其使用的现有科学证据进行批判性分析。由于血栓由血小板和凝血因子组成，有效的抗血栓策略包括使用一种抗凝剂和两种或更多种抗血小板药物。普通肝素传统上一直是最常用的抗凝剂，但正迅速被相对较新的药物如低分子量肝素、直接凝血酶抑制剂和Xa因子抑制剂所取代。近年来，随着更有效、起效更快的药物如普拉格雷和替卡格雷的出现，抗血小板药物领域发生了显著变化。这些药物已证明，在接受侵入性治疗或其他治疗的急性冠状动脉综合征患者中，缺血性结局有显著降低，但人们对出血风险增加有所担忧。糖蛋白IIb/IIIa抑制剂在接受双联抗血小板预处理的高危非ST段抬高型急性冠状动脉综合征患者中具有既定作用，但其在接受侵入性治疗和双联抗血小板治疗的ST段抬高型心肌梗死患者中的作用在各项研究中并未得到一致支持。此外，近年来，其作为直接冠状动脉内注射疗法的地位也受到了研究，结果不一。总之，精心制定的抗血栓策略需要考虑每个患者的个体风险因素和临床表现，努力在预防缺血性结局和减少出血并发症之间取得平衡。
