Guedeney Paul, Collet Jean-Philippe
Sorbonne Université, ACTION Study Group, INSERM UMRS_1166, Institut de Cardiologie, Pitié Salpêtrière (AP-HP), Paris, France.
Thromb Haemost. 2021 Jul;121(7):854-866. doi: 10.1055/s-0040-1722188. Epub 2021 Jan 27.
A few decades ago, the understanding of the pathophysiological processes involved in the coronary artery thrombus formation has placed anticoagulant and antiplatelet agents at the core of the management of acute coronary syndrome (ACS). Increasingly potent antithrombotic agents have since been evaluated, in various association, timing, or dosage, in numerous randomized controlled trials to interrupt the initial thrombus formation, prevent ischemic complications, and ultimately improve survival. Primary percutaneous coronary intervention, initial parenteral anticoagulation, and dual antiplatelet therapy with potent P2Y inhibitors have become the hallmark of ACS management revolutionizing its prognosis. Despite these many improvements, much more remains to be done to optimize the onset of action of the various antithrombotic therapies, for further treating and preventing thrombotic events without exposing the patients to an unbearable hemorrhagic risk. The availability of various potent P2Y inhibitors has opened the door for individualized therapeutic strategies based on the clinical setting as well as the ischemic and bleeding risk of the patients, while the added value of aspirin has been recently challenged. The strategy of dual-pathway inhibition with P2Y inhibitors and low-dose non-vitamin K antagonist oral anticoagulant has brought promising results for the early and late management of patients presenting with ACS with and without indication for oral anticoagulation. In this updated review, we aimed at describing the evidence supporting the current gold standard of antithrombotic management of ACS. More importantly, we provide an overview of some of the ongoing issues and promising therapeutic strategies of this ever-evolving topic.
几十年前，对冠状动脉血栓形成所涉及的病理生理过程的理解，使抗凝剂和抗血小板药物成为急性冠状动脉综合征（ACS）治疗的核心。此后，在众多随机对照试验中，人们对越来越强效的抗血栓药物进行了评估，评估内容包括各种联合用药、用药时机或剂量，以阻断初始血栓形成、预防缺血性并发症，并最终提高生存率。直接经皮冠状动脉介入治疗、初始胃肠外抗凝治疗以及使用强效P2Y抑制剂的双重抗血小板治疗，已成为ACS治疗的标志，彻底改变了其预后。尽管有了这些诸多改进，但要优化各种抗血栓治疗的起效时间，在不使患者面临难以承受的出血风险的情况下进一步治疗和预防血栓形成事件，仍有许多工作要做。各种强效P2Y抑制剂的出现，为基于临床情况以及患者的缺血和出血风险的个体化治疗策略打开了大门，而阿司匹林的附加价值最近受到了挑战。使用P2Y抑制剂和低剂量非维生素K拮抗剂口服抗凝剂进行双途径抑制的策略，对于有或没有口服抗凝指征的ACS患者的早期和晚期治疗都带来了有希望的结果。在这篇更新的综述中，我们旨在描述支持当前ACS抗血栓治疗金标准的证据。更重要的是，我们概述了这个不断发展的主题中一些当前存在的问题和有前景的治疗策略。
