Cardiology Unit, Big Metropolitan Hospital, BBM, Reggio Calabria, Italy.
Cardiology Division, Cannizzaro Hospital, Catania, Italy.
J Cardiovasc Pharmacol Ther. 2020 Sep;25(5):391-398. doi: 10.1177/1074248420923528. Epub 2020 May 11.
Antithrombotic drugs, which include antiplatelets and anticoagulants, are effective in prevention and treatment of many cardiovascular disorders such as acute coronary syndromes, stroke, and venous thromboembolism and are among the drugs most commonly prescribed worldwide. The advent of direct oral anticoagulants, which are safer alternatives to vitamin K antagonists and do not require laboratory monitoring, has revolutionized the treatment of nonvalvular atrial fibrillation and venous thromboembolism. The combination of oral anticoagulant and antiplatelet therapy is required in many conditions of great clinical impact such as the coexistence of atrial fibrillation and coronary artery disease, with indication to percutaneous coronary intervention. However, strategies that combine anticoagulant and antiplatelet therapies lead to a significant increase in bleeding rates and it is crucial to find the right combination in the single patient in order to optimize the ischemic and bleeding risk. The aim of this review is to explore the evidence and controversies regarding the optimal combination of anticoagulant and antiplatelet therapy through the consideration of past dogmas and new perspectives from recent clinical trials and to propose a tailored therapeutic approach, according to specific clinical scenarios and individual patient characteristics. In particular, we separately explored the clinical settings of stable and acute coronary syndromes and percutaneous revascularization in patients with atrial fibrillation.
抗血栓药物，包括抗血小板和抗凝药物，在预防和治疗许多心血管疾病方面非常有效，如急性冠状动脉综合征、中风和静脉血栓栓塞，是全球最常用的药物之一。直接口服抗凝药物的出现，为维生素 K 拮抗剂的更安全替代品，且无需实验室监测，彻底改变了非瓣膜性心房颤动和静脉血栓栓塞的治疗方法。在许多具有重大临床影响的情况下，如心房颤动和冠状动脉疾病并存并需要经皮冠状动脉介入治疗的情况下，需要联合使用口服抗凝剂和抗血小板治疗。然而，抗凝和抗血小板治疗的联合策略会导致出血率显著增加，因此在单个患者中找到正确的联合治疗方案至关重要，以优化缺血和出血风险。本综述的目的是通过考虑过去的教条和来自最近临床试验的新观点，探讨抗凝和抗血小板治疗联合应用的最佳证据和争议，并根据特定的临床情况和个体患者特征提出个体化的治疗方法。特别是，我们分别探讨了心房颤动患者稳定型和急性冠状动脉综合征以及经皮血运重建的临床情况。
