University of Florida College of Medicine-Jacksonville, Division of Cardiology-ACC Building 5th floor, 655 West 8th Street, Jacksonville, Florida 32209, USA.
Nat Rev Cardiol. 2017 Jun;14(6):361-379. doi: 10.1038/nrcardio.2017.18. Epub 2017 Feb 23.
Antithrombotic therapy, including antiplatelet and anticoagulant agents, is the cornerstone of pharmacological treatment to optimize clinical outcomes in patients with ST-segment elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PPCI). Intravenous anticoagulant drugs available for PPCI include the indirect thrombin inhibitors unfractionated heparin and low-molecular-weight heparin, and the direct thrombin inhibitor bivalirudin. Intravenous antiplatelet drugs mainly include glycoprotein IIb/IIIa inhibitors and the P2Y-receptor inhibitor cangrelor. Dual antiplatelet therapy with aspirin and an oral P2Y-receptor inhibitor is pivotal for the acute and long-term treatment of patients with STEMI undergoing PPCI. Prasugrel and ticagrelor provide a more prompt, potent, and predictable antiplatelet effect compared with clopidogrel, which translates into better clinical outcomes. Therefore, these agents are the first-line treatment in PPCI. However, patients can still experience adverse ischaemic events, which might be in part attributed to alternative pathways triggering thrombosis. Thrombin has an important role, suggesting the need for strategies directly targeting circulating thrombin or other factors of the coagulation cascade, such as oral anticoagulants (rivaroxaban), and the thrombin receptor on the platelet membrane (vorapaxar). In this Review, we provide an overview of currently available antithrombotic therapies used in patients with STEMI undergoing PPCI, results from pivotal clinical trials and their implications for guidelines, as well as recommendations for clinical practice.
抗血栓治疗，包括抗血小板和抗凝药物，是优化行直接经皮冠状动脉介入治疗（PPCI）的 ST 段抬高型心肌梗死（STEMI）患者临床结局的基石。可用于 PPCI 的静脉抗凝药物包括非 肝素和低分子肝素等间接凝血酶抑制剂，以及比伐卢定等直接凝血酶抑制剂。静脉抗血小板药物主要包括糖蛋白 IIb/IIIa 抑制剂和 P2Y12 受体抑制剂坎格瑞洛。双联抗血小板治疗，即阿司匹林联合口服 P2Y12 受体抑制剂，对行 PPCI 的 STEMI 患者的急性期和长期治疗至关重要。与氯吡格雷相比，普拉格雷和替格瑞洛可提供更迅速、更强、更可预测的抗血小板作用，从而带来更好的临床结局。因此，这些药物是 PPCI 的一线治疗药物。然而，患者仍可能发生不良缺血事件，这在一定程度上可能归因于触发血栓形成的替代途径。凝血酶起着重要作用，这提示需要采用直接靶向循环凝血酶或凝血级联其他因子的策略，例如口服抗凝剂（利伐沙班）和血小板膜上的凝血酶受体（沃拉帕沙）。在本篇综述中，我们概述了目前用于行 PPCI 的 STEMI 患者的抗血栓治疗方法、关键性临床试验结果及其对指南的意义，以及临床实践建议。
