Cheng Judy W M
1Department of Pharmacy Practice.
J Cardiovasc Pharmacol Ther. 2013 Nov;18(6):514-24. doi: 10.1177/1074248413499971.
Antiplatelet therapy is a cornerstone in coronary artery disease management. However, patients with acute coronary syndrome still remain at risk of recurrent cardiovascular events despite the advance of medical therapy.
This article provides a review of antiplatelet agents used in cardiovascular diseases and focus on updates in the past 5 years.
Peer-reviewed clinical trials and relevant treatment guidelines were identified from MEDLINE and Current Content database (from 1966 to April 15, 2013) using search terms aspirin, clopidogrel, prasugrel, ticagrelor, glycoprotein IIb/IIIa inhibitors, antiplatelet agents, coronary artery disease, acute coronary syndrome, pharmacology, pharmacokinetics, and pharmacodynamics. Citations from the available articles were also reviewed for additional references.
In unstable angina and non-ST-segment elevation myocardial infarction (MI), dual antiplatelet therapy (aspirin and clopidogrel) demonstrated a reduction in death from cardiovascular causes, nonfatal MI, or stroke (relative risk 0.80; 95% confidence interval [CI], 0.72-0.90). In ST-segment elevation MI, dual antiplatelet therapy reduced the rate of occluded infarct-related artery/death or recurrent MI (95% CI, 24%-47%). Newer agents such as prasugrel, when compared to clopidogrel, reduced death from vascular causes, MI, or stroke in patients undergoing percutaneous coronary intervention (PCI; hazard ratio [HR], 0.81; 95% CI 0.73-0.90) but not in those receiving medical management only. When compared to clopidogrel, ticagrelor reduces death from vascular causes, MI, or stroke (HR: 0.84; 95% CI, 0.77-0.92) in patients undergoing PCI or receiving medical management only. Both the agents, however, increase the risk of bleeding in certain patient population.
In the last 5 years, newer antiplatelet agents, including prasugrel and ticagrelor, have been demonstrated to reduce recurrent cardiovascular events compared to standard therapy and, however, also caused increase bleeding in selected patient populations. Newer agents including shorter acting P2Y12 inhibitor or antiplatelets that target other receptors are being evaluated to improve/maintain therapeutic efficacy yet minimize the risk of bleeding.
抗血小板治疗是冠状动脉疾病管理的基石。然而，尽管医学治疗取得了进展，但急性冠状动脉综合征患者仍有发生心血管事件复发的风险。
本文综述了用于心血管疾病的抗血小板药物，并重点介绍过去5年的进展。
使用搜索词阿司匹林、氯吡格雷、普拉格雷、替格瑞洛、糖蛋白IIb/IIIa抑制剂、抗血小板药物、冠状动脉疾病、急性冠状动脉综合征、药理学、药代动力学和药效学，从MEDLINE和Current Content数据库（1966年至2013年4月15日）中检索经过同行评审的临床试验和相关治疗指南。还对现有文章的参考文献进行了审查以获取更多参考资料。
在不稳定型心绞痛和非ST段抬高型心肌梗死（MI）中，双联抗血小板治疗（阿司匹林和氯吡格雷）显示心血管原因导致的死亡、非致命性MI或中风有所减少（相对风险0.80；95%置信区间[CI]，0.72 - 0.90）。在ST段抬高型MI中，双联抗血小板治疗降低了梗死相关动脉闭塞/死亡或复发性MI的发生率（95%CI，24% - 47%）。与氯吡格雷相比，新型药物如普拉格雷可降低接受经皮冠状动脉介入治疗（PCI）患者的血管原因导致的死亡、MI或中风发生率（风险比[HR]，0.81；95%CI 0.73 - 0.90），但仅接受药物治疗的患者中未降低。与氯吡格雷相比，替格瑞洛可降低接受PCI或仅接受药物治疗患者的血管原因导致的死亡、MI或中风发生率（HR：0.84；95%CI，0.77 - 0.92）。然而，这两种药物在某些患者群体中都会增加出血风险。
在过去5年中，已证明包括普拉格雷和替格瑞洛在内的新型抗血小板药物与标准治疗相比可减少心血管事件复发，然而，在特定患者群体中也会增加出血风险。正在评估包括作用时间更短的P2Y12抑制剂或靶向其他受体的抗血小板药物等新型药物，以提高/维持治疗效果并将出血风险降至最低。
