Parker William A E, Storey Robert F
Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, UK.
Heart. 2016 May 15;102(10):783-9. doi: 10.1136/heartjnl-2015-307858. Epub 2016 Feb 8.
Dual antiplatelet therapy (DAPT) is standard treatment for patients with acute coronary syndromes (ACS), typically comprising the use of aspirin with either an irreversible thienopyridine P2Y12 inhibitor, clopidogrel or prasugrel, or reversibly binding ticagrelor. Pivotal studies led to guidelines recommending DAPT for up to 12 months post-ACS. Despite this, there remains a significant burden of coronary artery disease (CAD)-related events up to and after this period. Recent meta-analyses, including both patients with ACS and patients with stable CAD treated with DAPT following percutaneous coronary intervention, have suggested that long-term thienopyridine-based DAPT reduces the risks of myocardial infarction (MI) and stent thrombosis but may paradoxically increase all-cause mortality risk. The PEGASUS-TIMI 54 (Prevention of Cardiovascular Events in Patients with Prior Heart Attack Using Ticagrelor Compared to Placebo on a Background of Aspirin - Thrombolysis in Myocardial Infarction 54) study examined the effects of long-term DAPT with aspirin and ticagrelor, compared with aspirin alone, on major adverse cardiovascular events (MACE) and complications, including bleeding in patients with prior history of MI. It showed that, over a 3-year period, ticagrelor reduced the risk of MACE but increased non-fatal bleeding risk. Overall, the PEGASUS-TIMI 54 results demonstrate that patients with a history of ACS deemed to be at high risk of further ischaemic events, particularly those in whom the risks of ischaemic events and cardiovascular death outweigh the risk of life-threatening bleeding, may benefit from prolonged ticagrelor-based DAPT. Guidelines are emerging which reflect this. The relationship between aspirin and ticagrelor, particularly with regard to aspirin dosing, remains to be fully elucidated and attention has recently been turned to the option of ticagrelor monotherapy. Future studies will explore optimal individualised strategies for long-term antiplatelet therapy.
双联抗血小板治疗（DAPT）是急性冠状动脉综合征（ACS）患者的标准治疗方法，通常包括将阿司匹林与不可逆的噻吩并吡啶P2Y12抑制剂（氯吡格雷或普拉格雷）或可逆结合的替格瑞洛联合使用。关键研究促使指南推荐在ACS后长达12个月内进行DAPT。尽管如此，在此期间及之后，冠状动脉疾病（CAD）相关事件的负担仍然很重。最近的荟萃分析，包括ACS患者和经皮冠状动脉介入治疗后接受DAPT治疗的稳定CAD患者，表明长期基于噻吩并吡啶的DAPT可降低心肌梗死（MI）和支架血栓形成的风险，但可能反常地增加全因死亡风险。PEGASUS-TIMI 54（在阿司匹林背景下使用替格瑞洛与安慰剂比较预防既往心肌梗死患者心血管事件 - 心肌梗死溶栓54）研究考察了与单独使用阿司匹林相比，长期使用阿司匹林和替格瑞洛进行DAPT对主要不良心血管事件（MACE）和并发症（包括既往有MI病史患者的出血）的影响。结果显示，在3年期间，替格瑞洛降低了MACE风险，但增加了非致命性出血风险。总体而言，PEGASUS-TIMI 54结果表明，被认为有进一步缺血事件高风险的ACS病史患者，特别是那些缺血事件和心血管死亡风险超过危及生命出血风险的患者，可能从延长的基于替格瑞洛的DAPT中获益。反映这一点的指南正在出现。阿司匹林与替格瑞洛之间的关系，特别是关于阿司匹林剂量方面，仍有待充分阐明，最近人们的注意力已转向替格瑞洛单药治疗的选择。未来的研究将探索长期抗血小板治疗的最佳个体化策略。
