Division of Cardiology, University of Washington, 1959 NE Pacific St., Box 356422, HSB BB552, Seattle, WA, 98195-6422, USA.
Department of Medicine, University of Washington, Seattle, WA, USA.
Curr Atheroscler Rep. 2018 Jan 19;20(1):4. doi: 10.1007/s11883-018-0703-4.
Coronary heart disease (CHD) and atrial fibrillation (AF) are among the most common cardiovascular diseases. A significant proportion of patients have both CHD and AF and are at increased risk for thrombotic complications. Current therapy for CHD and AF includes antiplatelet and anticoagulant medications, respectively. Patients with concurrent CHD and AF may be prescribed dual antiplatelet therapy (DAPT) in addition to anticoagulation, which increases their bleeding risk. Controversy remains on how to balance risks and benefits in patients with CHD and AF in which multiple antithrombotic therapies may be indicated.
We review clinical trials and current guidelines for antiplatelet and anticoagulant therapy in CHD and AF. Aspirin and P2Y inhibitors are the mainstay of antiplatelet therapy. Vitamin K antagonists (VKAs) are the most commonly used anticoagulant, although the use of non-VKA oral anticoagulants (NOACs) in patients with AF is increasing. Recent studies provide guidance on how to address antithrombotic therapies in patients with concomitant CHD and AF. To date, we have evidence that in patients with AF who undergo percutaneous coronary intervention (PCI), clopidogrel with VKA may be used safely without aspirin. Also, low-dose rivaroxaban in combination with either clopidogrel only or DAPT is as effective as the traditional regimen of triple therapy with VKA and DAPT with lower bleeding risk. Dabigatran with a P2Y inhibitor was also found to be safe with less bleeding compared to triple therapy with VKA and DAPT. Use of a single antiplatelet agent with anticoagulation has become a viable choice in patients with CHD and AF, but more clinical trial data is needed to confirm therapy and duration regimens.
冠心病（CHD）和心房颤动（AF）是最常见的心血管疾病之一。相当一部分患者同时患有 CHD 和 AF，血栓并发症风险增加。目前 CHD 和 AF 的治疗分别包括抗血小板和抗凝药物。同时患有 CHD 和 AF 的患者可能需要联合抗血小板和抗凝治疗（DAPT），这会增加其出血风险。对于需要多种抗血栓治疗的 CHD 和 AF 患者，如何平衡风险和获益仍存在争议。
我们回顾了 CHD 和 AF 抗血小板和抗凝治疗的临床试验和当前指南。阿司匹林和 P2Y 抑制剂是抗血小板治疗的主要药物。维生素 K 拮抗剂（VKAs）是最常用的抗凝药物，尽管在 AF 患者中使用非维生素 K 拮抗剂口服抗凝剂（NOACs）的情况正在增加。最近的研究为同时患有 CHD 和 AF 的患者的抗血栓治疗提供了指导。迄今为止，我们有证据表明，在接受经皮冠状动脉介入治疗（PCI）的 AF 患者中，氯吡格雷联合 VKA 可安全使用而无需使用阿司匹林。此外，低剂量利伐沙班联合氯吡格雷或 DAPT 与传统的 VKA 和 DAPT 三联治疗方案一样有效，且出血风险较低。与 VKA 和 DAPT 三联治疗相比，达比加群联合 P2Y 抑制剂的出血风险更低且安全。对于 CHD 和 AF 患者，联合抗血小板和抗凝治疗已成为一种可行的选择，但需要更多的临床试验数据来证实治疗和持续时间方案。
