Center for Interventional Cardiovascular Research and Clinical Trials, The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1030, New York, NY 10029-6574, USA.
Department of Biomedical Sciences, Humanitas University, Pieve Emanuele-Milan, Italy.
Eur Heart J. 2023 May 21;44(20):1780-1794. doi: 10.1093/eurheartj/ehad119.
Remarkable progress has been made in the pharmacological management of patients with cardiovascular disease, including the frequent use of antithrombotic agents. Nonetheless, bleeding complications remain frequent and potentially life-threatening. Therapeutic interventions relying on prompt antithrombotic drug reversal or removal have been developed to assist clinicians in treating patients with active bleeding or an imminent threat of major bleeding due to urgent surgery or invasive procedures. Early phase studies on these novel strategies have shown promising results using surrogate pharmacodynamic endpoints. However, the benefit of reversing/removing antiplatelet or anticoagulant drugs should always be weighed against the possible prothrombotic effects associated with withdrawal of antithrombotic protection, bleeding, and surgical trauma. Understanding the ischemic-bleeding risk tradeoff of antithrombotic drug reversal and removal strategies in the context of urgent high-risk settings requires dedicated clinical investigations, but challenges in trial design remain, with relevant practical, financial, and ethical implications.
在心血管疾病患者的药物治疗管理方面取得了显著进展，包括经常使用抗血栓药物。尽管如此，出血并发症仍然很常见，并且有潜在的生命威胁。已经开发出依赖于迅速逆转或清除抗血栓药物的治疗干预措施，以帮助临床医生治疗因紧急手术或侵入性操作而出现活动性出血或即将发生大出血的患者。这些新策略的早期研究使用替代的药效学终点显示出有希望的结果。然而，逆转/清除抗血小板或抗凝药物的益处应该始终与因停用抗血栓保护、出血和手术创伤而可能导致的血栓形成相关的影响相权衡。在紧急高危情况下，了解抗血栓药物逆转和清除策略的缺血-出血风险权衡需要专门的临床研究，但试验设计仍然存在挑战，涉及相关的实际、财务和伦理问题。
