Department of General Surgery, Pennsylvania Hospital, University of Pennsylvania Health System, School of Nursing, University of Pennsylvania, Philadelphia, USA.
J Cardiovasc Nurs. 2013 Sep-Oct;28(5):483-94. doi: 10.1097/JCN.0b013e31826173ba.
Percutaneous coronary intervention (PCI) is a proven treatment option for patients with acute coronary syndrome (ACS). Treatment of this patient population with antiplatelet therapy before and after percutaneous coronary intervention (PCI) is ever-changing. Combining clopidogrel, a thienopyridine, with aspirin has become the gold standard dual antiplatelet therapy. However, new research reveals several limitations with clopidogrel, including potential drug-drug interactions, slow onset of action, irreversibility of platelet inhibition, and a wide array of patient responses. A new thienopyridine, prasugrel, has been approved and supported by the current guidelines for its faster onset of action, lack of significant drug-drug interaction, and consistent patient response.
This article will present a background of ACS and the 2 thienopyridines (prasugrel and clopidogrel), provide a comprehensive analysis of 4 recent trials comparing the 2 drugs in patients with ACS undergoing PCI, and pose 2 further research questions involving the genetic variability and the optimum duration of antiplatelet therapy after PCI.
The American College of Cardiology/American Heart Association guidelines support prasugrel in patients specifically with ST-segment elevation myocardial infarction, non-ST-segment elevation myocardial infarction, previous or current stent restenosis or occlusion, and diabetes. Relative contraindications in patients using prasugrel include bleeding tendencies, age greater than 75 years, and body weight less than 60 kg. Absolute contraindications of prasugrel use include history or current stroke and active bleeding. With further research looking at duration of treatment and cardiovascular events with prasugrel and clopidogrel, clinicians will be able to make more evidence-based decisions.
Prasugrel has been shown to be an effective alternative to clopidogrel in treating patients with dual antiplatelet therapy for ACS requiring PCI. Awareness of the risks and benefits when deciding to prescribe clopidogrel or prasugrel for patients with ACS during and after PCI will promote patient safety, improve patient outcomes, and support evidence-based practice.
经皮冠状动脉介入治疗（PCI）是急性冠状动脉综合征（ACS）患者的一种经过验证的治疗选择。在 PCI 之前和之后，对接受抗血小板治疗的这一患者群体的治疗方法一直在变化。将噻吩吡啶类的氯吡格雷与阿司匹林联合使用已经成为金标准的双联抗血小板治疗。然而，新的研究揭示了氯吡格雷的一些局限性，包括潜在的药物相互作用、作用起效较慢、血小板抑制不可逆转以及广泛的患者反应。一种新的噻吩吡啶类药物普拉格雷已被批准，并得到当前指南的支持，因其起效更快、无显著药物相互作用以及患者反应一致。
本文将介绍 ACS 的背景以及两种噻吩吡啶类药物（普拉格雷和氯吡格雷），全面分析四项比较两种药物在接受 PCI 的 ACS 患者中的近期试验，并提出两个进一步的研究问题，涉及基因变异性和 PCI 后抗血小板治疗的最佳持续时间。
美国心脏病学会/美国心脏协会指南支持普拉格雷用于特定患者，包括 ST 段抬高型心肌梗死、非 ST 段抬高型心肌梗死、既往或当前支架再狭窄或闭塞以及糖尿病患者。普拉格雷在使用方面的相对禁忌证包括出血倾向、年龄大于 75 岁以及体重小于 60 公斤。普拉格雷使用的绝对禁忌证包括既往或当前卒中以及活动性出血。随着进一步研究关注普拉格雷和氯吡格雷治疗的持续时间和心血管事件，临床医生将能够做出更基于证据的决策。
普拉格雷已被证明在需要 PCI 的 ACS 患者的双联抗血小板治疗中是氯吡格雷的有效替代药物。在决定为 ACS 患者开具氯吡格雷或普拉格雷处方时，了解风险和益处将提高患者安全性、改善患者结局并支持基于证据的实践。
