Degrauwe Sophie, Pilgrim Thomas, Aminian Adel, Noble Stephane, Meier Pascal, Iglesias Juan F
Department of Cardiology, Lausanne University Hospital, Lausanne, Switzerland.
Department of Cardiology, Bern University Hospital, Bern, Switzerland.
Open Heart. 2017 Oct 15;4(2):e000651. doi: 10.1136/openhrt-2017-000651. eCollection 2017.
Dual antiplatelet therapy (DAPT) combining aspirin and a P2Y receptor inhibitor has been consistently shown to reduce recurrent major adverse cardiovascular events (MACE) in patients with acute coronary syndrome (ACS) or undergoing percutaneous coronary intervention (PCI) for stable coronary artery disease (CAD) compared with aspirin monotherapy, but at the expense of an increased risk of major bleeding. Nevertheless, the optimal duration of DAPT for secondary prevention of CAD remains uncertain, owing to the conflicting results of several large randomised trials. Among patients with stable CAD undergoing PCI with drug-eluting stents (DES), shorter durations of DAPT (3-6 months) were shown non-inferior to 12 or 24 months duration with respect to MACE, but reduced the rates of major bleeding. Contrariwise, prolonged DAPT durations (18-48 months) reduced the incidence of myocardial infarction and stent thrombosis, but at a cost of an increased risk of major bleeding and all-cause mortality. Until more evidence becomes available, the choice of optimal DAPT regimen and duration for patients with CAD requires a tailored approach based on the patient clinical presentation, baseline risk profile and management strategy. Future studies are however needed to identify patients who may derive benefit from shortened or extended DAPT courses for secondary prevention of CAD based on their individual ischaemic and bleeding risk. Based on limited evidence, 12 months duration of DAPT is currently recommended in patients with ACS irrespective of their management strategy, but large ongoing randomised trials are currently assessing the efficacy and safety of a short-term DAPT strategy (3-6 months) for patients with ACS undergoing PCI with newer generation DES. Finally, several ongoing, large-scale, randomised trials are challenging the current concept of DAPT by investigating P2Y receptor inhibitors as single antiplatelet therapy and may potentially shift the paradigm of antiplatelet therapy after PCI in the near future. This article provides a contemporary state-of-the-art review of the current evidence on DAPT for secondary prevention of patients with CAD and its future perspectives.
与阿司匹林单药治疗相比，联合使用阿司匹林和P2Y受体抑制剂的双重抗血小板治疗（DAPT）已被一致证明可降低急性冠状动脉综合征（ACS）患者或因稳定型冠状动脉疾病（CAD）接受经皮冠状动脉介入治疗（PCI）患者的复发性主要不良心血管事件（MACE），但代价是大出血风险增加。然而，由于几项大型随机试验结果相互矛盾，DAPT用于CAD二级预防的最佳持续时间仍不确定。在接受药物洗脱支架（DES）PCI的稳定型CAD患者中，较短疗程的DAPT（3 - 6个月）在MACE方面不劣于12或24个月疗程，但降低了大出血发生率。相反，延长DAPT疗程（18 - 48个月）可降低心肌梗死和支架血栓形成的发生率，但代价是大出血风险和全因死亡率增加。在获得更多证据之前，为CAD患者选择最佳的DAPT方案和持续时间需要根据患者的临床表现、基线风险状况和管理策略进行量身定制。然而，未来需要开展研究，以确定哪些患者基于其个体缺血和出血风险可能从缩短或延长的DAPT疗程中获益，从而进行CAD二级预防。基于有限的证据，目前推荐ACS患者无论其管理策略如何，均采用12个月的DAPT疗程，但目前正在进行的大型随机试验正在评估短期DAPT策略（3 - 6个月）对接受新一代DES PCI的ACS患者的疗效和安全性。最后，几项正在进行的大规模随机试验正在通过研究将P2Y受体抑制剂作为单一抗血小板治疗来挑战当前的DAPT概念，并可能在不久的将来改变PCI后抗血小板治疗的模式。本文对目前关于DAPT用于CAD患者二级预防的证据及其未来前景进行了当代最新综述。
