Inova Center for Thrombosis Research and Drug Development, Inova Heart and Vascular Institute, Falls Church, VA, USA.
Sussex Cardiac Centre, Brighton and Sussex University Hospitals NHS Trust and Faculty of Medicine, Brighton and Sussex Medical School, Brighton, UK.
Prog Cardiovasc Dis. 2018 Jan-Feb;60(4-5):460-470. doi: 10.1016/j.pcad.2018.01.003. Epub 2018 Jan 12.
The P2Y receptor plays a critical role in the amplification of platelet aggregation in response to various agonists and stable thrombus generation at the site of vascular injury leading to deleterious ischemic complications. Therefore, treatment with a P2Y receptor blocker is a major effective strategy to prevent ischemic complications in high-risk patients with acute coronary syndrome (ACS) and patients undergoing percutaneous coronary intervention (PCI). The determination of optimal platelet inhibition is based on maximizing antithrombotic properties while minimizing bleeding risk and is critically dependent on individual patient's propensity for thrombotic and bleeding risks. Immediately after ACS and during PCI, where highly elevated thrombotic activity is present, a loading dose administration with a potent P2Y receptor blocker such as ticagrelor or prasugrel is preferred. In stable coronary artery disease patients undergoing PCI, clopidogrel is widely used. In addition, in patients with ST-segment elevation myocardial infraction who cannot take oral medications, a fast acting intravenous glycoprotein IIb/IIIa inhibitor or P2Y receptor blocker, cangrelor, may add clinical benefits. During long term therapy, a strategy that prevents ischemic risk while avoiding excessive bleeding risk is similarly desired. Although up to one year dual antiplatelet therapy (DAPT) is recommended in patients undergoing elective stenting, the available data support the anti-ischemic benefit of prolonged DAPT (more than1 year) in patients with prior MI. In addition to the DAPT risk calculator tool, future risk assessment methods that analyze intrinsic thrombogenicity and atherosclerotic coronary burden may further identify the optimal candidate for prolonged DAPT to improve net clinical outcomes.
P2Y 受体在各种激动剂刺激下血小板聚集的放大和血管损伤部位稳定血栓形成中起着关键作用，导致有害的缺血性并发症。因此，使用 P2Y 受体阻滞剂治疗是预防急性冠脉综合征（ACS）高危患者和经皮冠状动脉介入治疗（PCI）患者缺血性并发症的主要有效策略。最佳血小板抑制的确定基于最大限度地提高抗血栓特性，同时最小化出血风险，这严重依赖于个体患者的血栓形成和出血风险倾向。在 ACS 后和 PCI 期间，存在高度升高的血栓形成活性，优选给予强效 P2Y 受体阻滞剂（如替格瑞洛或普拉格雷）的负荷剂量。在接受 PCI 的稳定型冠状动脉疾病患者中，氯吡格雷广泛应用。此外，对于不能口服药物的 ST 段抬高型心肌梗死患者，快速作用的静脉内糖蛋白 IIb/IIIa 抑制剂或 P2Y 受体阻滞剂坎格瑞洛可能会增加临床获益。在长期治疗中，同样希望采取一种既能预防缺血风险又能避免过度出血风险的策略。尽管推荐接受择期支架置入术的患者进行长达一年的双联抗血小板治疗（DAPT），但现有数据支持在既往有心肌梗死的患者中延长 DAPT（超过 1 年）具有抗缺血益处。除了 DAPT 风险计算器工具外，未来分析内在血栓形成性和动脉粥样硬化性冠状动脉负担的风险评估方法可能会进一步确定延长 DAPT 的最佳候选者，以改善净临床结局。
