Koziński Marek, Rejszel-Baranowska Joanna, Młodawska Elżbieta, Siller-Matula Jolanta M, Tomaszuk-Kazberuk Anna
Department of Cardiology and Internal Medicine, Medical University of Gdansk, Gdynia, Poland.
Department of Cardiology, Medical University of Bialystok, Bialystok, Poland.
Postepy Kardiol Interwencyjnej. 2020 Jun;16(2):127-137. doi: 10.5114/aic.2020.96055. Epub 2020 Jun 23.
Selection of the optimal peri- and postprocedural antithrombotic regimen in patients with atrial fibrillation (AF) undergoing percutaneous coronary intervention (PCI) is a common clinical problem which may pose a challenge to medical practitioners. This systematic review summarizes the updated evidence on this topic. Non-vitamin K oral anticoagulants (NOACs) at standard doses are the preferred option in most of post PCI patients with AF, except those few with a clear indication for a vitamin K antagonist (VKA). Reduced NOAC doses should be considered in dabigatran- or rivaroxaban-treated patients with a high bleeding risk, which prevail over concerns about stent thrombosis or ischemic stroke. There is insufficient evidence to favor one NOAC over another in this setting. In the early post stenting period, triple therapy comprising a NOAC, clopidogrel and aspirin is recommended. Timing of post PCI aspirin cessation should be based on a careful analysis of the bleeding and ischemic risk. There is only low quality evidence regarding the optimal approach to elective or urgent/emergency PCI procedures in patients requiring oral anticoagulation. It is suggested that there is no need of interruption of VKA and PCI procedure should be performed via radial artery access with a lower dose of unfractionated heparin. On the other hand, NOACs are usually stopped before elective PCIs, while urgent/emergency procedures may be performed with the addition of low-dose parenteral anticoagulation.
对于接受经皮冠状动脉介入治疗（PCI）的心房颤动（AF）患者，选择最佳的围手术期和术后抗栓方案是一个常见的临床问题，可能给医生带来挑战。本系统评价总结了关于该主题的最新证据。在大多数接受PCI治疗的AF患者中，标准剂量的非维生素K口服抗凝剂（NOACs）是首选，除非少数患者有明确的维生素K拮抗剂（VKA）使用指征。对于出血风险高的达比加群或利伐沙班治疗患者，应考虑降低NOAC剂量，这比支架血栓形成或缺血性卒中的担忧更为重要。在这种情况下，没有足够的证据支持一种NOAC优于另一种。在支架置入术后早期，推荐使用由一种NOAC、氯吡格雷和阿司匹林组成的三联疗法。PCI术后停用阿司匹林的时机应基于对出血和缺血风险的仔细分析。对于需要口服抗凝治疗的患者，关于择期或紧急/急诊PCI手术的最佳方法只有低质量的证据。建议无需中断VKA，应通过桡动脉途径进行PCI手术，并使用较低剂量的普通肝素。另一方面，NOACs通常在择期PCI术前停用，而紧急/急诊手术可在加用低剂量胃肠外抗凝剂的情况下进行。
