Heart and Vascular Center, Guthrie/Robert Packer Hospital, Sayre, PA.
Geisinger Commonwealth School of Medicine, Scranton, PA.
J Cardiovasc Pharmacol. 2019 Aug;74(2):82-90. doi: 10.1097/FJC.0000000000000697.
The objective of this article is to review the contemporary literature on the use of antithrombotic therapy in patients with atrial fibrillation (AF) and coronary artery disease after undergoing percutaneous coronary intervention (PCI). Special consideration was given to the type and duration of therapy, treatment strategies for the elderly (≥65 years of age), and strategies to reduce bleeding.
Relevant studies were searched through MEDLINE/PubMed, Web of Science, Cochrane Library, ClinicalTrials.gov, and Google Scholar. Of the 236 publications retrieved, 76 were considered relevant including 35 randomized controlled trials, 17 meta-analyses, 16 observational studies, and 8 published major guidelines.
Most trials, meta-analyses, and guidelines support 1 month of triple therapy (TT) with an oral anticoagulant (OAC), dual antiplatelet agents (DAPT) with aspirin (ASA)/clopidogrel, and, afterward, dual therapy (DT) with OAC and single antiplatelet agent for an additional 11 months, or alternatively DT alone for 12 months after PCI. Individual consideration is given to the risk and impact of stent thrombosis (ST), thromboembolism, and bleeding. Several trials and meta-analyses have also suggested that shorter DAPT duration (≤6 months) may be safer than longer therapy (≥6 months) when weighing the risk of bleeding with ischemic outcomes, especially with newer generation drug-eluting stents. The selective use of proton-pump inhibitors in patients prone to gastrointestinal bleeding who are subjected to prolonged exposure with TT or DT may be beneficial. In the elderly, the risk of bleeding from TT, compared with DT, outweighs the benefit of reducing ischemic events.
In conclusion, tailoring therapy to the individual patient is recommended considering the ischemic and bleeding risk as well as the risk of thromboembolism. For most patients with AF, 1 month of TT and subsequently DT for additional 11 months are recommended.
本文旨在回顾经皮冠状动脉介入治疗（PCI）后合并心房颤动（AF）和冠状动脉疾病患者应用抗血栓治疗的当代文献。特别关注治疗的类型和持续时间、老年患者（≥65 岁）的治疗策略以及减少出血的策略。
通过 MEDLINE/PubMed、Web of Science、Cochrane 图书馆、ClinicalTrials.gov 和 Google Scholar 检索相关研究。在检索到的 236 篇文献中，有 76 篇被认为是相关的，包括 35 项随机对照试验、17 项荟萃分析、16 项观察性研究和 8 项已发表的主要指南。
大多数试验、荟萃分析和指南支持在 PCI 后 1 个月内采用三联疗法（TT），即口服抗凝剂（OAC）联合双抗血小板药物（DAPT）阿司匹林（ASA）/氯吡格雷，随后再使用 OAC 和单抗血小板药物进行 11 个月的双联治疗（DT），或者在 PCI 后 12 个月单独使用 DT。在权衡支架血栓形成（ST）、血栓栓塞和出血的风险和影响时，需要个别考虑。几项试验和荟萃分析还表明，与较长的治疗时间（≥6 个月）相比，较短的 DAPT 持续时间（≤6 个月）可能更安全，尤其是在使用新一代药物洗脱支架时，在权衡出血风险与缺血结局方面。在接受 TT 或 DT 长期暴露的易发生胃肠道出血的患者中选择性使用质子泵抑制剂可能是有益的。在老年人中，与 DT 相比，TT 的出血风险超过了减少缺血事件的获益。
总之，建议根据个体患者的缺血和出血风险以及血栓栓塞风险来调整治疗方案。对于大多数合并 AF 的患者，推荐使用 1 个月的 TT，随后进行 11 个月的 DT。
