Alkhalil Mohammad, Džavík Vladimír, Bhatt Deepak L, Mehran Roxana, Mehta Shamir R
Division of Cardiology, Peter Munk Cardiac Centre, Toronto General Hospital, Toronto, Canada.
Cardiothoracic Centre, Freeman Hospital, Newcastle-upon-Tyne, UK.
Curr Cardiol Rep. 2022 Mar;24(3):277-293. doi: 10.1007/s11886-022-01645-0. Epub 2022 Mar 16.
The evidence for use of dual antiplatelet therapy (DAPT) for patients undergoing percutaneous coronary intervention (PCI) in the elective setting is relatively sparse and is based on data from more than two decades ago. We will review the evidence supporting the use of DAPT with focus on stable patients undergoing elective PCI, including the role of potent PY inhibitors, modified DAPT durations, and more recently, aspirin discontinuation.
Clopidogrel is the recommended PY inhibitor in the elective PCI setting. The benefit of more potent PY inhibitors such as ticagrelor or prasugrel in stable patients is unproven, but their use might be reasonable in those with high clinical or angiographic features of increased ischemic risk without increased risk of bleeding. Moreover, extending DAPT beyond 12 months is associated with a reduction in ischemic events but also increased bleeding. In contrast, shortening DAPT (3-6 months) reduces bleeding compared with 1 year of treatment, but it is also probably associated with increased ischemic events, mainly in higher-risk patients undergoing complex PCI. Recently, early aspirin discontinuation at 3 months (and perhaps as early as 1 month) following PCI reduces bleeding, with no evidence to suggest an increase in ischemic events. Clopidogrel is the PY inhibitor of choice, while more data are required to support the use of more potent PY inhibitors in stable patients. The duration of DAPT should be tailored to individual patient ischemic and bleeding risks. New strategies, such as early aspirin discontinuation, are promising to reduce bleeding risk without increase in ischemic risk.
在择期经皮冠状动脉介入治疗（PCI）患者中使用双联抗血小板治疗（DAPT）的证据相对较少，且基于二十多年前的数据。我们将回顾支持使用DAPT的证据，重点关注接受择期PCI的稳定患者，包括强效P2Y抑制剂的作用、调整DAPT疗程，以及最近的阿司匹林停用。
氯吡格雷是择期PCI情况下推荐使用的P2Y抑制剂。替格瑞洛或普拉格雷等更强效的P2Y抑制剂在稳定患者中的益处尚未得到证实，但在那些具有高临床或血管造影特征提示缺血风险增加且无出血风险增加的患者中使用可能是合理的。此外，将DAPT疗程延长至12个月以上与缺血事件减少相关，但出血也会增加。相比之下，与1年治疗相比，缩短DAPT疗程（3 - 6个月）可减少出血，但也可能与缺血事件增加有关，主要发生在接受复杂PCI的高危患者中。最近，PCI术后3个月（可能早在1个月）早期停用阿司匹林可减少出血，且无证据表明缺血事件增加。氯吡格雷是首选的P2Y抑制剂，而在稳定患者中使用更强效的P2Y抑制剂还需要更多数据支持。DAPT疗程应根据患者个体的缺血和出血风险进行调整。新策略，如早期停用阿司匹林，有望在不增加缺血风险的情况下降低出血风险。
