Colonna Paolo, Abrignani Maurizio G, Colivicchi Furio, Verdecchia Paolo, Alunni Gianfranco, Bongo Angelo S, Ceravolo Roberto, Oliva Fabrizio, Rakar Serena, Riccio Carmine, Scherillo Marino, Valle Roberto, Bovenzi Francesco
U.O. di Cardiologia Ospedaliera, Zaienda Ospedaliero-Universitaria Consorziale Policlinico, Bari.
G Ital Cardiol (Rome). 2013 Apr;14(4):295-322. doi: 10.1714/1257.13889.
The introduction in the therapeutic armamentarium of three new oral anticoagulants for the prevention of thromboembolism in atrial fibrillation (AF) has stimulated the development of this position paper from the Italian Association of Hospital Cardiologists (ANMCO). First, the pathophysiology of arterial thromboembolism in AF is reviewed, describing the mechanisms of action of the new oral anticoagulants, their pharmacology and pharmacokinetics, and highlighting differences and similarities observed in preclinical studies and trials. Stratification of thromboembolic and bleeding risk is made using different risk scores; a comprehensive analysis of the various international guidelines should emphasize convergences or divergences. An in-depth examination of the limitations of current therapeutic strategies for the prevention of stroke in non-valvular AF provides insight into the difficulty in maintaining adequate adherence to therapy with warfarin and a constant and effective anticoagulation, without wide fluctuations in prothrombin time international normalized ratio (INR) values. Clinical trials of new oral anticoagulants for AF are discussed in detail in the present document, with a focus on similarities and differences, efficacy and safety data, and the net clinical benefit of each new oral anticoagulant. Results obtained in elderly patients, or in patients with renal, liver and ischemic heart disease or previous stroke are reported separately, as well as those regarding combination therapy with antiplatelet agents. Finally, this document provides indications, practical applications and cost-effectiveness analysis of each new oral anticoagulant. It is of utmost importance to know how treatment should be started, how you should switch from warfarin, which patients should be maintained on warfarin, how and when cardioversion, catheter ablation or appendage closure should be performed, what drug and food interactions may affect these medications, and how treatment adherence may be improved to avoid therapy discontinuation. An accurate examination of the risk of bleeding is also provided, with special reference to laboratory monitoring of renal and hepatic function, timing for discontinuing these medications prior to surgery, and treatment of patients with major and minor bleeding.
三种新型口服抗凝剂被引入用于预防心房颤动（AF）血栓栓塞的治疗药库，这促使意大利医院心脏病学家协会（ANMCO）撰写了本立场文件。首先，回顾了AF动脉血栓栓塞的病理生理学，描述了新型口服抗凝剂的作用机制、药理学和药代动力学，并强调了在临床前研究和试验中观察到的异同。使用不同的风险评分对血栓栓塞和出血风险进行分层；对各种国际指南的全面分析应强调趋同或分歧。深入研究非瓣膜性AF预防中风的当前治疗策略的局限性，有助于深入了解维持对华法林治疗的充分依从性以及持续有效的抗凝治疗的困难，同时避免凝血酶原时间国际标准化比值（INR）值出现大幅波动。本文详细讨论了新型口服抗凝剂用于AF的临床试验，重点关注异同、疗效和安全性数据以及每种新型口服抗凝剂的净临床获益。分别报告了老年患者、患有肾、肝和缺血性心脏病或既往有中风的患者的研究结果，以及与抗血小板药物联合治疗的结果。最后，本文提供了每种新型口服抗凝剂的适应证、实际应用和成本效益分析。了解治疗应如何开始、如何从华法林转换、哪些患者应继续使用华法林治疗、应如何以及何时进行心脏复律、导管消融或心耳封堵、哪些药物和食物相互作用可能影响这些药物，以及如何提高治疗依从性以避免治疗中断至关重要。还提供了对出血风险的准确评估，特别提及肾功能和肝功能的实验室监测情况、手术前停用这些药物的时机以及对大出血和小出血患者的治疗。
