Emergency Clinical County Hospital of Baia Mare, Romania.
"Vasile Goldis" University, Faculty of Medicine Arad, Romania.
Am J Ther. 2019 Mar/Apr;26(2):e184-e197. doi: 10.1097/MJT.0000000000000913.
In patients with acute coronary syndrome (ACS), a persistent hypercoagulable state has been demonstrated and antithrombin therapy in addition to platelet inhibition has been proposed.
Vitamin K antagonists (VKAs) were used as oral anticoagulant (OAC) therapy and produced mixed results whereas trials are still ongoing with non-vitamin K OACs (NOACs).
A literature search regarding benefits and risks of different OAC therapies in ACS was conducted through MEDLINE and EMBASE (last 20 years until September 2018).
Patients receiving dual antiplatelet therapy (DAPT) in combination with NOAC are to be considered at high bleeding risk. Rivaroxaban 2.5 mg BID in triple therapy with DAPT, rivaroxaban 15 mg, or dabigatran 110/150 mg BID in dual therapy with P2Y12 inhibitor (mainly clopidogrel) is safer in terms of bleeding risk than triple therapy with VKA plus DAPT. The reduction in ischemic events by NOACs was most promising when added to single antiplatelet therapy. Ongoing trials with apixaban and edoxaban could clarify whether dual therapy NOACs with P2Y12 inhibitor sufficiently protect against stent thrombosis or myocardial infarction and are safer in terms of bleeding risk than a dual therapy with a VKA and clopidogrel. In the absence of randomized trials, it is unknown whether dual therapy with NOAC and aspirin could be an alternative to NOAC and a P2Y12 inhibitor. Thus, the overall benefit of adding NOAC to antiplatelet treatment after ACS in patients without clear indication for long-term OAC is still unknown.
Different OACs have been tested as antithrombotic therapy after ACS in combination with single or DAPT and led to a modest reduction in ischemic events. Further studies evaluating NOACs in combination with single antiplatelet therapy or shorter duration of triple antithrombotic therapy are warranted.
在急性冠脉综合征（ACS）患者中，已证实存在持续的高凝状态，除了血小板抑制外，还提出了使用抗凝血酶治疗。
维生素 K 拮抗剂（VKAs）曾被用作口服抗凝剂（OAC）治疗，但结果喜忧参半，而使用非维生素 K OAC（NOAC）的试验仍在进行中。
通过 MEDLINE 和 EMBASE（截至 2018 年 9 月的过去 20 年）对 ACS 中不同 OAC 治疗的益处和风险进行了文献检索。
接受双重抗血小板治疗（DAPT）联合 NOAC 的患者被认为有较高的出血风险。在 DAPT 三联疗法中，瑞马唑仑 2.5mg BID，或在 DAPT 双联疗法中，瑞马唑仑 15mg 或达比加群 110/150mg BID，与华法林加 DAPT 三联疗法相比，出血风险更低。与 DAPT 双联疗法相比，NOAC 加用单种抗血小板治疗在减少缺血事件方面更有前景。正在进行的阿哌沙班和依度沙班试验可以阐明，NOAC 双联疗法联合 P2Y12 抑制剂是否足以预防支架血栓形成或心肌梗死，且出血风险低于华法林加氯吡格雷的双联疗法。在缺乏随机试验的情况下，尚不清楚 NOAC 加用阿司匹林与 NOAC 加用 P2Y12 抑制剂相比是否可以作为替代方案。因此，在没有长期 OAC 明确指征的 ACS 患者中，在抗血小板治疗的基础上添加 NOAC 是否具有总体获益仍不清楚。
不同的 OAC 已被测试作为 ACS 后的抗血栓治疗，与单药或 DAPT 联合使用，并导致缺血事件的发生率略有降低。需要进一步研究评估 NOAC 与单种抗血小板治疗联合使用或缩短三联抗血栓治疗的时间。
