Montreal Heart Institute, Department of Medicine, Université de Montréal, Montréal, Québec, Canada; Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina, USA.
Division of Cardiology, Hamilton General Hospital, Hamilton Health Sciences, McMaster University, and Population Health Research Institute, McMaster University Hamilton Health Sciences, Hamilton, Ontario, Canada.
Can J Cardiol. 2020 Aug;36(8):1298-1307. doi: 10.1016/j.cjca.2019.12.013. Epub 2019 Dec 16.
Antiplatelet therapy for patients with coronary artery disease has evolved dramatically over the last decade. P2Y12 inhibitors offering more potent and consistent platelet inhibition than clopidogrel are now widely available, dual antiplatelet therapy (DAPT) duration can be tailored to individual ischemic and bleeding risks, and strategies to personalize antiplatelet therapy have been developed when concomitant oral anticoagulation (OAC) is indicated. Scientific societies from Canada, the United States, and Europe have all published updated recommendations addressing antiplatelet therapy in the recent years. The purpose of this review is to put the Canadian guidelines into perspective vis-à-vis international recommendations by highlighting similarities and critically analyzing differences. We focus on 3 major topics relevant for clinical practice: DAPT duration following drug-eluting stent implantation, DAPT following percutaneous coronary intervention in patients with concomitant indications for OAC, and DAPT management for noncardiac surgery following drug-eluting stent implantation. Although guidelines broadly agree on the majority of recommendations, the justifications for major differences were contrasted in the manuscript. Unanswered questions remain, including the place of aspirin in secondary prevention of coronary artery disease in the contemporary era, aspirin-free strategies early after percutaneous coronary intervention, and the safe minimal duration of DAPT with newer generation stents.
在过去的十年中，针对冠心病患者的抗血小板治疗发生了重大变化。目前广泛应用的 P2Y12 抑制剂比氯吡格雷具有更强、更一致的血小板抑制作用，可根据个体缺血和出血风险调整双联抗血小板治疗（DAPT）的持续时间，当需要同时进行口服抗凝治疗（OAC）时，还制定了个体化抗血小板治疗策略。来自加拿大、美国和欧洲的科学学会近年来都发布了更新的抗血小板治疗建议。本文旨在通过突出相似点和批判性分析差异，将加拿大指南与国际建议进行对比。我们重点关注与临床实践相关的 3 个主要话题：药物洗脱支架植入术后的 DAPT 持续时间、同时有 OAC 适应证的经皮冠状动脉介入治疗后的 DAPT 以及药物洗脱支架植入术后非心脏手术后的 DAPT 管理。尽管指南在大多数建议上基本一致，但本文对比了主要差异的理由。仍存在一些未解决的问题，包括阿司匹林在当代冠心病二级预防中的地位、经皮冠状动脉介入术后早期的无阿司匹林策略，以及新一代支架下 DAPT 的安全最短持续时间。
