Division of Cardiology, Hirakata Kohsai Hospital, Hirakata, Japan.
Department of Cardiovascular Medicine, Saga University, Saga, Japan.
Am J Cardiol. 2024 Sep 1;226:83-96. doi: 10.1016/j.amjcard.2024.07.002. Epub 2024 Jul 6.
The current guidelines for acute coronary syndrome (ACS) discourage the use of anticoagulation after percutaneous coronary intervention (PCI) without specific indications, although the recommendation is not well supported by evidence. In this post hoc analysis of the ShorT and OPtimal Duration of Dual AntiPlatelet Therapy-3 (STOPDAPT-3) trial, 30-day outcomes were compared between the 2 groups with and without post-PCI heparin administration among patients with ACS who did not receive mechanical support devices. The co-primary end points were the bleeding end point, defined as the Bleeding Academic Research Consortium type 3 or 5 bleeding, and the cardiovascular end point, defined as a composite of cardiovascular death, myocardial infarction, definite stent thrombosis, or ischemic stroke. Among 4,088 patients with ACS, 2,339 patients (57.2%) received post-PCI heparin. The proportion of patients receiving post-PCI heparin was higher among those with ST-elevation myocardial infarction compared with others (72.3% and 38.8%, p <0.001), and among patients with intraprocedural adverse angiographic findings compared with those without (67.6% and 47.5%, p <0.001). Post-PCI heparin compared with no post-PCI heparin was associated with a significantly increased risk of the bleeding end point (4.75% and 2.52%, adjusted hazard ratio 1.69, 95% confidence interval 1.15 to 2.46, p = 0.007) and a numerically increased risk of the cardiovascular end point (3.16% and 1.72%, adjusted hazard ratio 1.56, 95% confidence interval 0.98 to 2.46, p = 0.06). Higher hourly dose or total doses of heparin were also associated with higher incidence of both bleeding and cardiovascular events within 30 days. In conclusion, post-PCI anticoagulation with unfractionated heparin was frequently implemented in patients with ACS. Post-PCI heparin use was associated with harm in terms of increased bleeding without the benefit of reducing cardiovascular events. Trial identifier: STOPDAPT-3 ClinicalTrials.gov number, NCT04609111.
目前的急性冠状动脉综合征（ACS）指南不鼓励在没有具体指征的情况下在经皮冠状动脉介入治疗（PCI）后使用抗凝剂，尽管这一建议没有得到充分的证据支持。在 ShorT 和 OPtimal Duration of Dual AntiPlatelet Therapy-3（STOPDAPT-3）试验的这项事后分析中，比较了 ACS 患者中未接受机械支持装置的两组患者在 PCI 后是否使用肝素的 30 天结局。主要复合终点是出血终点，定义为 Bleeding Academic Research Consortium 3 型或 5 型出血；心血管终点定义为心血管死亡、心肌梗死、明确的支架血栓形成或缺血性卒中的复合终点。在 4088 例 ACS 患者中，2339 例（57.2%）患者接受了 PCI 后肝素治疗。ST 段抬高型心肌梗死患者接受 PCI 后肝素治疗的比例高于其他患者（72.3%和 38.8%，p<0.001），且术中出现不良血管造影结果的患者高于无此结果的患者（67.6%和 47.5%，p<0.001）。与不使用 PCI 后肝素相比，使用 PCI 后肝素与出血终点风险显著增加相关（4.75%和 2.52%，调整后的危险比 1.69，95%置信区间 1.15 至 2.46，p=0.007），心血管终点风险也有增加的趋势（3.16%和 1.72%，调整后的危险比 1.56，95%置信区间 0.98 至 2.46，p=0.06）。肝素的每小时剂量或总剂量较高也与 30 天内出血和心血管事件的发生率增加相关。总之，ACS 患者中经常使用 PCI 后抗凝剂普通肝素。PCI 后使用肝素与出血风险增加相关，而没有减少心血管事件的获益。试验标识符：STOPDAPT-3；ClinicalTrials.gov 编号，NCT04609111。
