Greco Antonio, Mauro Maria Sara, Capodanno Davide, Angiolillo Dominick J
Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico - San Marco", 95125 Catania, Italy.
Division of Cardiology, University of Florida College of Medicine, Jacksonville, FL 32209, USA.
Rev Cardiovasc Med. 2022 Oct 17;23(10):348. doi: 10.31083/j.rcm2310348. eCollection 2022 Oct.
Following percutaneous coronary intervention (PCI), an initial course of dual antiplatelet therapy (DAPT) with aspirin and a inhibitor ( -i) is recommended to minimize the risk of thrombotic complications. After the initial period of DAPT, antiplatelet monotherapy, usually consisting of aspirin, is administered for long-term secondary prevention. However, over the last few years there has been accruing evidence on -i monotherapy, both in the acute (i.e., post-PCI; after a brief period of DAPT, transitioning to monotherapy before six or 12 months in patients with chronic or acute coronary syndrome, respectively) and chronic (i.e., long-term secondary prevention; after completion of six or 12 months of DAPT, in patients with chronic or acute coronary syndrome, respectively) settings. In aggregate, most studies of short DAPT with transition to -i monotherapy showed a reduced risk of bleeding complications, without any significant increase in ischemic events as compared to standard DAPT. On the other hand, the evidence on long-term -i monotherapy is scarce, but results from a randomized trial showed that clopidogrel monotherapy outperformed aspirin monotherapy in terms of net benefit, ischemic events and bleeding. Antiplatelet therapy is also recommended for patients undergoing PCI and with an established indication for long-term oral anticoagulation (OAC). In this scenario, a brief period of triple therapy (i.e., aspirin, -i and OAC) is followed by a course of dual antithrombotic therapy (usually with -i and OAC) and ultimately by lifelong OAC alone. European and American guidelines have been recently updated to provide new recommendations on antithrombotic therapy, including the endorsement of -i monotherapy in different settings. However, some areas of uncertainty still remain and further randomized investigations are ongoing to fulfil current gaps in knowledge. In this review, we assess the current knowledge and evidence on -i monotherapy for the early and long-term secondary prevention in patients undergoing PCI, and explore upcoming research and future directions in the field.
经皮冠状动脉介入治疗（PCI）后，建议采用阿司匹林和一种抑制剂（-i）进行初始疗程的双联抗血小板治疗（DAPT），以将血栓形成并发症的风险降至最低。在DAPT的初始阶段之后，通常采用以阿司匹林为主的抗血小板单药治疗进行长期二级预防。然而，在过去几年中，关于-i单药治疗在急性（即PCI术后；在短暂的DAPT疗程后，分别在慢性或急性冠状动脉综合征患者中于6个月或12个月之前过渡到单药治疗）和慢性（即长期二级预防；分别在慢性或急性冠状动脉综合征患者中完成6个月或12个月的DAPT疗程后）情况下的证据不断积累。总体而言，大多数关于短期DAPT并过渡到-i单药治疗的研究表明，与标准DAPT相比，出血并发症风险降低，且缺血事件无显著增加。另一方面，关于长期-i单药治疗的证据较少，但一项随机试验的结果显示，氯吡格雷单药治疗在净获益、缺血事件和出血方面优于阿司匹林单药治疗。对于接受PCI且有长期口服抗凝（OAC）既定指征的患者，也建议进行抗血小板治疗。在这种情况下，先进行短期的三联治疗（即阿司匹林、-i和OAC），随后进行一个疗程的双联抗栓治疗（通常是-i和OAC），最终仅进行终身OAC治疗。欧洲和美国的指南最近已更新，以提供关于抗栓治疗的新建议，包括认可在不同情况下采用-i单药治疗。然而，仍存在一些不确定领域，正在进行进一步的随机研究以填补当前的知识空白。在本综述中，我们评估了关于-i单药治疗在接受PCI患者的早期和长期二级预防方面的现有知识和证据，并探讨该领域即将开展的研究和未来方向。
