Alshahrani Ali, O'Nunain Sean
Faculty of Biology, Medicine and Health, School of Health Sciences, University of Manchester, Oxford Road, Greater Manchester, UK.
Department of Invasive Cardiovascular Technology, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Kingdom of Saudi Arabia.
Egypt Heart J. 2023 Aug 28;75(1):74. doi: 10.1186/s43044-023-00402-0.
Optimal antithrombotic therapy depicts a challenge to clinicians treating atrial fibrillation (AF) patients who are undergoing percutaneous coronary intervention (PCI). Theoretically, these patients would require a combination therapy of oral anticoagulant and dual antiplatelet therapy (DAPT) with aspirin and a P2Y12 inhibitor, known as triple antithrombotic therapy (TAT). However, TAT is known to carry a significant risk of bleeding. The purpose of the present paper is to provide a focused review of the evidence about the safety of TAT as well as to address contemporary directions regarding antithrombotic therapy following PCI in patients with AF who received a drug-eluting stent.
Novel oral anticoagulant studies consistently demonstrated a better safety profile when compared to Vitamin K antagonist (warfarin), especially in AF patients who have other indications of DAPT after PCI. Evidence from several studies showed that the use of TAT in AF patients undergoing stent implantation or PCI has no significant clinical benefit with more risk of major bleeding when compared to DAT. Therefore, the current recommendations for AF have taken into account the mounting evidence of antithrombotic treatment after PCI in AF patients, which has caused a major shift away from the TAT strategy toward DAT over time.
Cardiologists face challenges in determining the best antithrombotic treatment for AF patients after PCI with DES implantation. Growing data suggest that TAT is associated with considerable bleeding and worse safety, without significant effectiveness. Hence, TAT is strictly applied for individuals with significant thrombotic risk and low bleeding risk, and for a limited duration. This paper highlights the safety concerns of TAT and current trends in antithrombotic therapy after PCI in patients with AF and DES.
对于治疗接受经皮冠状动脉介入治疗（PCI）的心房颤动（AF）患者的临床医生而言，最佳抗栓治疗是一项挑战。从理论上讲，这些患者需要口服抗凝药与阿司匹林和P2Y12抑制剂的双重抗血小板治疗（DAPT）联合使用，即所谓的三联抗栓治疗（TAT）。然而，已知TAT具有显著的出血风险。本文的目的是对TAT安全性的证据进行重点综述，并探讨在接受药物洗脱支架的AF患者PCI术后抗栓治疗的当代方向。
新型口服抗凝药研究一致表明，与维生素K拮抗剂（华法林）相比，其安全性更好，尤其是在PCI术后有其他DAPT指征的AF患者中。多项研究的证据表明，与双联抗栓治疗（DAT）相比，在接受支架植入或PCI的AF患者中使用TAT没有显著的临床益处，且大出血风险更高。因此，目前针对AF的建议已考虑到AF患者PCI术后抗栓治疗的越来越多的证据，随着时间的推移，这已导致从TAT策略向DAT策略的重大转变。
心脏病专家在确定DES植入后AF患者的最佳抗栓治疗方案时面临挑战。越来越多的数据表明，TAT与大量出血和更差的安全性相关，且无显著疗效。因此，TAT严格应用于血栓形成风险高且出血风险低的个体，且应用时间有限。本文强调了TAT的安全性问题以及AF和DES患者PCI术后抗栓治疗的当前趋势。
