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CSA&TISC2019丨方堃教授畅谈房颤抗凝治疗的新突破与进展

2019-06-30 国际循环编辑部 国际循环

编者按:临床实践中,心房颤动(房颤)患者的抗凝治疗应作何选择?对于PCI治疗、存在左心室血栓或不明原因栓塞性卒中、发生出血等特殊情况的患者,其抗凝治疗应何去何从?这一直是房颤抗凝治疗领域的难点和焦点问题。6月28日,在CSA&TISC 2019脑血管危险因素预防与控制专场,复旦大学附属华山医院方堃教授结合最新临床研究及指南推荐对上述现实问题作了全面解析。

编者按:临床实践中,心房颤动(房颤)患者的抗凝治疗应作何选择?对于PCI治疗、存在左心室血栓或不明原因栓塞性卒中、发生出血等特殊情况的患者,其抗凝治疗应何去何从?这一直是房颤抗凝治疗领域的难点和焦点问题。6月28日,在CSA&TISC 2019脑血管危险因素预防与控制专场,复旦大学附属华山医院方堃教授结合最新临床研究及指南推荐对上述现实问题作了全面解析。

从临床研究到真实世界看抗凝治疗选择

随机对照临床试验结果可为临床实践提供循证医学支持。有关房颤抗凝治疗RE-LY研究显示,与华法林相比,两种剂量的达比加群均具有安全与疗效的获益。进一步亚组分析结果显示,不论患者既往有无卒中病史,达比加群对卒中或体循环栓塞、出血性卒中等结局的影响均不劣于华法林,甚至可能更优。真实世界数据无疑为临床实践提供最直观的指导。关于房颤抗凝治疗,FDA真实世界数据对134 000新用药房颤患者为期两年的随访显示,与华法林相比,达比加群可分别使缺血性卒中、颅内出血及死亡风险降低20%、66%和14%。更可喜的是,全球注册登记研究GLORIA-AF II期研究中的卒中和出血发生率均低于RE-LY研究欧洲处方事后分析的结果。

特殊情况抗栓管理问题聚焦

▣非瓣膜性房颤(NVAF)的PCI后抗栓管理

对行PCI治疗的房颤患者,临床实践中要权衡卒中/支架内血栓与出血风险。针对该类患者,一方面要积极预防卒中进行抗凝,另一方面要积极预防支架内血栓进行双联抗血小板治疗,从而降低卒中及支架内血栓发生风险。但仅仅这样考量还不够,还需权衡上述风险与出血风险。2014年欧洲指南推荐,对行PCI的房颤患者应尽量缩短三联治疗的时间,随后给予OAC+单个抗血小板药物。后续相关研究发现,三联抗栓治疗方案中抗血小板药物不尽相同。因此,2016及2017ESC指南均不推荐普拉格雷或替格瑞洛用于三联抗栓治疗。2019 AHA/ACC/HRS房颤管理指南更新明确指出,对因ACS行PCI支架置入且卒中风险高的房颤患者,三联抗栓时选择氯吡格雷而非普拉格雷合理;选择包含一种P2Y12抑制剂和剂量调整的维生素K拮抗剂的双联抗栓治疗(如氯吡格雷+达比加群150 mg bid)出血风险显著低于三联疗法。

▣出血后重启抗凝

对发生消化道大出血的房颤患者,到底是否要重新启动抗凝治疗?这需多学科协作进行综合评估决定。若患者存在出血部位不清楚、消化道多发性血管发育异常、没有可逆转的/可治疗的因素、抗凝治疗中断时发生出血、酗酒、PCI后需双联抗血小板和高龄等情况,则可能支持不重新启动抗凝。

对在口服抗凝药物治疗时出现颅内出血的患者,若情况紧急则应基于下图由患者或亲属向多学科专家团队告知相关情况,做进一步综合评估和判断。一般来说,若患者存在严重的颅内出血、多发的颅内微出血、无法逆转/治疗出血的原因、高龄、抗凝暂停期间的出血、在新型口服抗凝药正确剂量或低剂量治疗时发生的出血、未控制的高血压、酗酒和PCI后需双联抗血小板治疗则可倾向于不重启抗凝治疗。



▣左心室血栓

2013年ACCF/AHA指南推荐左心室血栓患者应口服抗凝药物治疗3个月;后来2017 ESC指南推荐在影像学检查指导下抗凝治疗6个月。研究发现,心脏MRI有助于发现左心室血栓的短期内缺血性卒中风险,能为左心室血栓患者的抗凝治疗提供重要指导信息。

▣不明原因的栓塞性卒中

对原因不明的缺血性脑卒中(SUE)可能源于心脏的节律异常、结构异常,亦可能源于大动脉病变、静脉血栓通过右向左分流或是小动脉病变。RE-SPECT ESUS研究显示,对于近期发生ESUS的患者,达比加群的大出血风险与阿司匹林相似。

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