Magnani B, Semprini F
Istituto di Malattie dell'Apparato Cardiovascolare, Università degli Studi, Bologna.
Cardiologia. 1994 Dec;39(12 Suppl 1):15-21.
Coronary atherosclerosis is the process underlying virtually all the clinical manifestations of ischemic heart disease. When ulcer or fissure in the fibrous cap of the atheroma occur, platelet adhesion to subendothelium, aggregation and further platelet recruitment culminate in thrombus formation. These mechanisms are known to be responsible for most cases of acute events in patients with ischemic heart disease. Inside platelets, aspirin blocks the synthesis of thromboxane A2 by irreversibly inhibiting cyclooxygenase. Aspirin is recommended not only for treatment of patients with acute coronary syndromes (unstable angina, acute myocardial infarction), but also for secondary prevention of vascular events in chronic coronary syndromes. Aspirin prevents myocardial infarction in patients with chronic stable angina and reduces mortality, reinfarction and stroke in survivors of an acute myocardial infarction. Aspirin, alone or in combination with dipyridamole, prevents early and late occlusion of aortocoronary vein grafts. It is useful also in patients undergoing coronary angioplasty. Such benefits extend to all patients regardless of age, sex, history of hypertension or diabetes. Higher daily doses (900-1500 mg) are not more effective than lower doses (75-325 mg). Other antiplatelet drugs are not more effective than aspirin, which has the best risk-to-benefit and cost-to-benefit ratios. Ticlopidine is a reasonable alternative for use in preventing vascular events among patients intolerant to aspirin. Warfarin is an effective antithrombotic alternative to aspirin for secondary prevention after a myocardial infarction. However aspirin is easier to administer and follow-up when compared with warfarin. Warfarin should be preferred in high risk patients with left ventricular dysfunction with or without a mural thrombus, and those with associated atrial fibrillation.
冠状动脉粥样硬化是几乎所有缺血性心脏病临床表现的潜在病理过程。当动脉粥样硬化斑块纤维帽发生溃疡或破裂时，血小板黏附于内皮下、聚集并进一步募集血小板，最终形成血栓。已知这些机制是缺血性心脏病患者大多数急性事件的原因。在血小板内，阿司匹林通过不可逆地抑制环氧化酶来阻断血栓素A2的合成。阿司匹林不仅被推荐用于治疗急性冠状动脉综合征（不稳定型心绞痛、急性心肌梗死）患者，还用于慢性冠状动脉综合征血管事件的二级预防。阿司匹林可预防慢性稳定型心绞痛患者发生心肌梗死，并降低急性心肌梗死幸存者的死亡率、再梗死率和卒中发生率。阿司匹林单独使用或与双嘧达莫联合使用，可预防主动脉冠状动脉静脉移植血管的早期和晚期闭塞。它对接受冠状动脉血管成形术的患者也有用。这些益处适用于所有患者，无论年龄、性别、高血压或糖尿病病史如何。较高的每日剂量（900 - 1500毫克）并不比较低剂量（75 - 325毫克）更有效。其他抗血小板药物并不比阿司匹林更有效，阿司匹林具有最佳的风险效益比和成本效益比。噻氯匹定是阿司匹林不耐受患者预防血管事件的合理替代药物。华法林是心肌梗死后二级预防中阿司匹林的有效抗栓替代药物。然而，与华法林相比，阿司匹林更易于给药和随访。对于有或无壁血栓的左心室功能不全的高危患者以及伴有房颤的患者，应优先选择华法林。
