Division of Cardiovascular Medicine, Ohashi Medical Center, Toho University, 2-22-36 Ohashi, Meguro-ku, Tokyo 153-8515, Japan.
Division of Cardiovascular Medicine, Ohashi Medical Center, Toho University, 2-22-36 Ohashi, Meguro-ku, Tokyo 153-8515, Japan.
J Cardiol. 2021 Aug;78(2):91-98. doi: 10.1016/j.jjcc.2020.12.004. Epub 2020 Dec 23.
Recent advances in percutaneous coronary intervention (PCI) technology and medication have changed the main focus of PCI from preventing ischemic to preventing bleeding events. Bleeding risk assessment is essential for preventing bleeding. Several types of assessment tools have been established, but they are heterogeneous, making interpretation, generalization, and comparison between trials difficult. In 2019, the Academic Research Consortium (ARC) introduced a new consensus document with 20 criteria to define high bleeding risk (HBR). The applicability of the ARCHBR criteria were subsequently investigated, and 4 studies have already demonstrated wide applicability worldwide, including in Japan. Nevertheless, it hase been suggested that bleeding risk is higher in people from East Asian countries than in people from Western countries. Patients with HBR have a 3-fold higher risk of major bleeding, and in Japan approximately 50% of patients undergoing PCI have HBR. In addition, patients with overlapping factors, such as older age, renal disease, and anemia, are at increased risk of bleeding, and each additional factor further increases the risk. In Japanese patients undergoing PCI, in addition to the ARC-HBR criteria, low body weight, heart failure, and peripheral arterial disease are high-risk subsets for bleeding. The addition of these factors to the ARCHBR criteria increases the prevalence of HBR in Japanese patients to 58% and improves the sensitivity of diagnostic evaluations. The additional factors are clinically important because they are often encountered in everyday practice, and Japan's newly updated guideline has adopted them as criteria for HBR. Studies found a temporal trend over the past 20 years of a gradual and consistent increase of bleeding risk. This finding contrasts with improved outcomes in people at risk of ischemic and thrombotic events. Therefore, further research is needed to eliminate the risk of bleeding while maintaining the efficacy of antithrombotic therapy after PCI.
经皮冠状动脉介入治疗（PCI）技术和药物的最新进展改变了 PCI 的主要焦点，从预防缺血事件转变为预防出血事件。出血风险评估对于预防出血至关重要。已经建立了几种类型的评估工具，但它们具有异质性，使得解释、概括和比较试验变得困难。2019 年，学术研究联盟（ARC）引入了一份新的共识文件，其中包含 20 项标准来定义高出血风险（HBR）。随后，对 ARCHBR 标准的适用性进行了研究，已有 4 项研究表明其在全球范围内具有广泛的适用性，包括在日本。然而，有人认为东亚国家的出血风险高于西方国家。HBR 患者大出血的风险增加 3 倍，在日本，大约 50%接受 PCI 的患者存在 HBR。此外，年龄较大、患有肾脏疾病和贫血等重叠因素的患者出血风险增加，每增加一个因素都会进一步增加风险。在日本接受 PCI 的患者中，除了 ARC-HBR 标准外，低体重、心力衰竭和外周动脉疾病也是出血的高危亚组。将这些因素添加到 ARCHBR 标准中，将日本患者中 HBR 的患病率提高到 58%，并提高了诊断评估的敏感性。这些附加因素具有临床意义，因为它们在日常实践中经常遇到，日本最新更新的指南已将其作为 HBR 的标准。研究发现，过去 20 年来，出血风险呈逐渐一致增加的趋势。这一发现与缺血和血栓形成事件风险人群的治疗结果改善形成对比。因此，需要进一步研究，在维持 PCI 后抗血栓治疗疗效的同时，消除出血风险。
