Olinic Dan-Mircea, Tataru Dan Alexandru, Homorodean Calin, Spinu Mihail, Olinic Maria
1 Medical Clinic no. 1, Iuliu Hațieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania.
Vasa. 2018 Feb;47(2):99-108. doi: 10.1024/0301-1526/a000676. Epub 2017 Nov 21.
This review treats antithrombotic use for peripheral arterial disease (PAD). In asymptomatic patients, there are no scientific data to support single antiplatelet therapy (SAPT) for primary prophylaxis. In symptomatic PAD, SAPT with aspirin or clopidogrel is indicated. The efficacy of aspirin is controversial. Clopidogrel may be preferred over aspirin. Ticagrelor is not superior to clopidogrel in reducing major adverse cardiovascular events and major adverse limb events, but lowers the risk of ischaemic stroke. In symptomatic PAD, dual antiplatelet therapy (DAPT) with clopidogrel and aspirin does not provide benefit over SAPT with aspirin alone and is associated with increased risk of major bleeding. DAPT with ticagrelor 60 mg b. i. d. and aspirin provides a significant major adverse cardiovascular events reduction in symptomatic PAD patients and may be considered in PAD patients with prior myocardial infarction. The use of a new thrombin receptor antagonist, vorapaxar, on top of SAPT or DAPT with aspirin and/or clopidogrel, reduces the risk of acute limb ischaemia and peripheral artery revascularization in patients with symptomatic PAD, at the cost of an increased risk for bleeding. Rivaroxaban (2.5 mg b. i. d.) plus aspirin (100 mg daily) is the first antithrombotic association that proved significant benefit for PAD patients, in terms of strong endpoints - total mortality and cardiovascular mortality. Therefore, this association shows the strongest evidence for secondary prevention of symptomatic PAD patients. In PAD patients undergoing percutaneous peripheral interventions, at least four weeks of DAPT with aspirin and clopidogrel is recommended after infrainguinal stent implantation. Stenting below-the-knee arteries is often followed by a longer period of DAPT, but no specific evidence is available. Anticoagulation is mandatory to prevent arterial occlusion during radial or brachial invasive procedures. The strategy includes use of unfractioned heparin, bivalirudin or enoxaparin. Vitamin K antagonists may be considered after autologous vein infrainguinal bypass.
本综述探讨外周动脉疾病（PAD）的抗血栓治疗应用。对于无症状患者，尚无科学数据支持采用单一抗血小板治疗（SAPT）进行一级预防。对于有症状的PAD患者，推荐使用阿司匹林或氯吡格雷进行SAPT。阿司匹林的疗效存在争议。氯吡格雷可能优于阿司匹林。替格瑞洛在降低主要不良心血管事件和主要不良肢体事件方面并不优于氯吡格雷，但可降低缺血性卒中风险。对于有症状的PAD患者，氯吡格雷与阿司匹林联合的双重抗血小板治疗（DAPT）并不比单独使用阿司匹林的SAPT更有益，且与大出血风险增加相关。每日两次服用60 mg替格瑞洛与阿司匹林联合的DAPT可显著降低有症状PAD患者的主要不良心血管事件，对于既往有心肌梗死的PAD患者可考虑使用。在阿司匹林和/或氯吡格雷的SAPT或DAPT基础上加用新型凝血酶受体拮抗剂沃拉帕沙，可降低有症状PAD患者急性肢体缺血和外周动脉血运重建的风险，但会增加出血风险。利伐沙班（每日两次，每次2.5 mg）加阿司匹林（每日100 mg）是首个在全因死亡率和心血管死亡率等主要终点方面被证明对PAD患者有显著益处的抗血栓联合用药。因此，这种联合用药为有症状PAD患者的二级预防提供了最有力的证据。对于接受经皮外周介入治疗的PAD患者，在膝下支架植入术后，建议至少进行四周的阿司匹林和氯吡格雷联合DAPT。膝下动脉支架置入术后通常需要更长时间的DAPT，但尚无具体证据。在桡动脉或肱动脉有创操作期间，抗凝对于预防动脉闭塞至关重要。该策略包括使用普通肝素、比伐卢定或依诺肝素。自体静脉膝下旁路术后可考虑使用维生素K拮抗剂。
