Department of Cardiology, Copenhagen University Hospital Gentofte, Hellerup, Denmark.
J Am Coll Cardiol. 2013 Sep 10;62(11):981-9. doi: 10.1016/j.jacc.2013.05.029. Epub 2013 Jun 7.
The purpose of this study was to investigate the risk of thrombosis and bleeding according to multiple antithrombotic treatment regimens in atrial fibrillation (AF) patients after myocardial infarction (MI) or percutaneous coronary intervention (PCI).
The optimal antithrombotic treatment strategy is unresolved in patients with multiple indications.
A total of 12,165 AF patients hospitalized with MI and/or undergoing PCI between 2001 and 2009 were identified by nationwide registries (60.7% male; mean age 75.6 years). Risk of MI/coronary death, ischemic stroke, and bleeding according to antithrombotic treatment regimen was estimated by Cox regression models.
Within 1 year, MI or coronary death, ischemic stroke, and bleeding events occurred in 2,255 patients (18.5%), 680 (5.6%), and 769 (6.3%), respectively. Relative to triple therapy (oral anticoagulation [OAC] plus aspirin plus clopidogrel), no increased risk of recurrent coronary events was seen for OAC plus clopidogrel (hazard ratio [HR]: 0.69, 95% confidence interval [CI]: 0.48 to 1.00), OAC plus aspirin (HR: 0.96, 95% CI: 0.77 to 1.19), or aspirin plus clopidogrel (HR: 1.17, 95% CI: 0.96 to 1.42), but aspirin plus clopidogrel was associated with a higher risk of ischemic stroke (HR: 1.50, 95% CI: 1.03 to 2.20). Also, OAC plus aspirin and aspirin plus clopidogrel were associated with a significant increased risk of all-cause death (HR: 1.52, 95% CI: 1.17 to 1.99 and HR: 1.60, 95% CI: 1.25 to 2.05, respectively). When compared to triple therapy, bleeding risk was nonsignificantly lower for OAC plus clopidogrel (HR: 0.78, 95% CI: 0.55 to 1.12) and significantly lower for OAC plus aspirin and aspirin plus clopidogrel.
In real-life AF patients with indication for multiple antithrombotic drugs after MI/PCI, OAC and clopidogrel was equal or better on both benefit and safety outcomes compared to triple therapy.
本研究旨在探讨心肌梗死（MI）或经皮冠状动脉介入治疗（PCI）后合并心房颤动（AF）患者的多种抗栓治疗方案与血栓栓塞和出血风险的关系。
对于具有多种适应证的患者，最佳抗栓治疗策略尚未确定。
通过全国性注册登记（60.7%为男性，平均年龄 75.6 岁），共纳入 2001 至 2009 年期间因 MI 和/或 PCI 住院的 12165 例 AF 患者。采用 Cox 回归模型估计抗栓治疗方案与 MI/冠状动脉死亡、缺血性卒中和出血风险的关系。
在 1 年内，2255 例（18.5%）患者发生 MI 或冠状动脉死亡、680 例（5.6%）患者发生缺血性卒中和 769 例（6.3%）患者发生出血事件。与三联治疗（口服抗凝药[OAC]加阿司匹林加氯吡格雷）相比，OAC 加氯吡格雷（风险比[HR]：0.69，95%置信区间[CI]：0.48 至 1.00）、OAC 加阿司匹林（HR：0.96，95%CI：0.77 至 1.19）或阿司匹林加氯吡格雷（HR：1.17，95%CI：0.96 至 1.42）并未增加复发性冠状动脉事件的风险，但阿司匹林加氯吡格雷与缺血性卒中风险增加相关（HR：1.50，95%CI：1.03 至 2.20）。此外，OAC 加阿司匹林和阿司匹林加氯吡格雷均与全因死亡风险显著增加相关（HR：1.52，95%CI：1.17 至 1.99 和 HR：1.60，95%CI：1.25 至 2.05）。与三联治疗相比，OAC 加氯吡格雷的出血风险无显著降低（HR：0.78，95%CI：0.55 至 1.12），OAC 加阿司匹林和阿司匹林加氯吡格雷的出血风险显著降低。
在 MI/PCI 后具有多种抗栓药物适应证的真实世界 AF 患者中，与三联治疗相比，OAC 和氯吡格雷在疗效和安全性方面均具有同等或更好的效果。
