Alfredsson Joakim, Roe Matthew T
Department of Cardiology and Department of Medical and Health Sciences, Linköping University, Linköping, Sweden,
Drug Saf. 2015 May;38(5):481-91. doi: 10.1007/s40264-015-0286-8.
The key pathophysiological process underlying symptomatic coronary artery disease, including acute coronary syndromes (ACS), is usually a rupture or an erosion of an atherosclerotic plaque, followed by platelet activation and subsequent thrombus formation. Early clinical trials showed benefit with long-term aspirin treatment, and later-based on large clinical trials-dual anti-platelet therapy (DAPT), initially with clopidogrel, and more recently with prasugrel or ticagrelor, has become the established treatment in the post-ACS setting and after percutaneous coronary intervention (PCI). Treatment with DAPT is recommended for both ST-elevation myocardial infarction and non-ST-elevation ACS, as well as after PCI with stenting, in American and European clinical guidelines. Notwithstanding the benefits observed with DAPT, including third-generation P2Y12 receptor inhibitors plus aspirin, ACS patients remain at high risk for a recurrent cardiovascular event, suggesting that other treatment strategies, including the addition of a third oral anti-platelet agent or a novel oral anticoagulant (NOAC) to standard DAPT regimens, may provide additional benefit for post-ACS patients and for patients undergoing PCI. Adding a third anti-thrombotic agent to DAPT after an ACS event or a PCI procedure has been shown to have modest benefit in terms of ischemic event reduction, but has consistently been associated with increased bleeding complications. Therefore, the quest to optimize anti-thrombotic therapies post-ACS and post-PCI continues unabated but is tempered by the historical experiences to date that indicate that careful patient and dose selection will be critical features of future randomized trials.
包括急性冠脉综合征（ACS）在内的有症状冠心病的关键病理生理过程通常是动脉粥样硬化斑块破裂或糜烂，随后血小板活化并形成血栓。早期临床试验显示长期使用阿司匹林治疗有益，后来基于大型临床试验，双联抗血小板治疗（DAPT），最初使用氯吡格雷，最近使用普拉格雷或替格瑞洛，已成为ACS后和经皮冠状动脉介入治疗（PCI）后的既定治疗方法。美国和欧洲的临床指南建议，对于ST段抬高型心肌梗死和非ST段抬高型ACS以及PCI术后植入支架的患者，均应采用DAPT治疗。尽管观察到DAPT（包括第三代P2Y12受体抑制剂加阿司匹林）有益，但ACS患者仍有较高的心血管事件复发风险，这表明其他治疗策略，包括在标准DAPT方案中添加第三种口服抗血小板药物或新型口服抗凝剂（NOAC），可能会为ACS后患者和接受PCI的患者带来额外益处。在ACS事件或PCI手术后，在DAPT基础上加用第三种抗栓药物已显示在减少缺血事件方面有适度益处，但一直与出血并发症增加相关。因此，优化ACS后和PCI后抗栓治疗的探索仍在继续，但鉴于迄今为止的历史经验，即仔细的患者和剂量选择将是未来随机试验的关键特征，这一探索受到了一定限制。
