Department of Medicine and Rehabilitation, Cardiac Rehabilitation Operative Unit, San Filippo Neri Hospital, Salus Infirmorum Clinic, Via della Lucchina 41, 00135, Rome, Italy.
IRCCS Fondazione Don Carlo Gnocchi, Milan, Italy.
Drugs. 2018 Sep;78(13):1309-1319. doi: 10.1007/s40265-018-0957-8.
One of the most common conundrums in all cardiovascular medicine pertains to the care of patients with atrial fibrillation after percutaneous coronary intervention, because of both dual antiplatelet therapy and oral anticoagulant therapy would seem to be necessary to reduce risks of stent thrombosis and thromboembolism, respectively, but also with an inevitable trade-off of more bleeding. Patients who require triple therapy are at high risk of both ischaemia and bleeding; therefore, defining a personalised secondary prevention strategy aimed at achieving the best net clinical benefit is essential. The good news is that we have entered an era of increased perceived and tangible safety that applies to both non-vitamin K-antagonist oral anticoagulants and newer drug-eluting stents. Even if the consistency across the major trials and the significantly lower risk of bleeding with dual therapy make it hard to argue that triple therapy should be used routinely, the aggregate evidence suggests that the net clinical benefit of dual therapy should give cardiologists confidence to drop aspirin when they are using a contemporary percutaneous coronary intervention strategy with drug-eluting stents. Waiting for more randomised trials and meta-analyses, for the time being, in patients not in clinical trials, full-dose oral triple therapy with dual antiplatelet agents and full-dose anticoagulation should be avoided as a routine practice, and the choice of the proper, that is, safer, oral anticoagulant, namely a non-vitamin K-antagonist oral anticoagulant, may be regarded by now as an additional bleeding avoiding strategy in patients with atrial fibrillation undergoing percutaneous coronary intervention.
在所有心血管医学中，最常见的难题之一涉及经皮冠状动脉介入治疗后房颤患者的治疗，因为双重抗血小板治疗和口服抗凝治疗似乎都是必要的，分别可降低支架血栓形成和血栓栓塞的风险，但也不可避免地会增加出血风险。需要三联治疗的患者缺血和出血风险都很高；因此，定义旨在实现最佳净临床获益的个体化二级预防策略至关重要。好消息是，我们已经进入了一个可感知和切实安全性增加的时代，这既适用于非维生素 K 拮抗剂口服抗凝剂，也适用于新型药物洗脱支架。即使主要试验的一致性以及双联治疗出血风险显著降低，使得很难论证三联治疗应该常规使用，但综合证据表明，双联治疗的净临床获益应该让心脏病专家有信心在使用药物洗脱支架的现代经皮冠状动脉介入治疗策略时停用阿司匹林。在等待更多随机试验和荟萃分析的同时，对于未参加临床试验的患者，应避免常规使用全剂量口服三联治疗（双联抗血小板药物和全剂量抗凝），并且选择适当的、即更安全的口服抗凝剂，即非维生素 K 拮抗剂口服抗凝剂，现在可能被视为接受经皮冠状动脉介入治疗的房颤患者的另一种避免出血的策略。
