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许轶洲:房颤患者冠脉支架术后的抗栓治疗

2017-01-03 佚名 365医学网订阅号

  摘要:当房颤的患者合并冠心病需要接受经皮冠状动脉介入治疗(PCI)时,其术后双联抗血小板治疗和长期抗凝治疗策略的安全性一直存在质疑和争议。本文就心房颤动患者冠脉支架术后的抗血栓治疗进行综述。   心房颤动是最常见的心律失常之一,国外对心房颤动的流行病学调查表明,一般人群心房颤动的总患病率约为0.4%-1.0%,且有随年龄增长上升的趋势。房颤动(房颤)和冠心病有着很多共同的危险因素,冠

  摘要:当房颤的患者合并冠心病需要接受经皮冠状动脉介入治疗(PCI)时,其术后双联抗血小板治疗和长期抗凝治疗策略的安全性一直存在质疑和争议。本文就心房颤动患者冠脉支架术后的抗血栓治疗进行综述。 


  心房颤动是最常见的心律失常之一,国外对心房颤动的流行病学调查表明,一般人群心房颤动的总患病率约为0.4%-1.0%,且有随年龄增长上升的趋势。房颤动(房颤)和冠心病有着很多共同的危险因素,冠心病患者中10%~15%同时伴有房颤,而心房颤动患者中约30%合并有冠心病。房颤血栓和冠状动脉内血栓形成机制不同,故其抗栓治疗方法也不相同,抗血小板治疗是冠心病二级预防及PCI后支架血栓预防的关键,而口服抗凝药物是心房颤动预防卒中最重要的治疗措施,因而,在需长期抗凝治疗的心房颤动患者接受冠状动脉支架置入后的抗血栓形成治疗是当今临床的常见棘手问题。本将针对房颤合并冠心病患者如何进行抗凝和抗血小板进行综述。 

一、冠状动脉支架植入术后的抗血栓治疗 

  由于临床试验证明,冠脉支架植入术后病人使用双联抗血小板疗法组比单用阿司匹林组或阿司匹林加华法林组明显减少心脏性死亡或心梗危险,而冠状动脉植入支架的患者如未接受双重抗血小板会使支架血栓形成和其他主要不良事件风险增加。无论是何种支架,植入后头1个月内支架血栓形成的发生率最高,1年后就会明显降低。故指南推荐为了减少支架内血栓的形成,植入裸支架者应该最少服用双联抗血小板疗法1月、最好服用持续一年,而植入药物涂层支架者最少服用一年。 

二、房颤患者血栓栓塞及抗凝治疗 

  CHADS2是目前确定心房颤动患者抗栓治疗策略的主要依据,而CHADS2—VASc评分系统增加了血管疾病、年龄(65~74岁)及女性3个危险因素,与CHADS2评分相比,CHADS2—VASc评分对卒中低危患者具有较好的血栓栓塞预测价值。而HAS-BLED评分系统被认为是应用口服抗凝药时出血风险评估最为简便可靠的方案。多项关于非瓣膜病心房颤动患者随机对照试验的研究显示,与口服阿司匹林或阿司匹林联用氯吡格雷相比,口服华法林会使得卒中或系统性栓塞风险明显降低。而新型抗凝药例如达比加群,不仅能很好预防栓塞事件而且会出血事件也明显少于华法林。 

三、三联抗血栓疗法的效果和安全性 

  针对于房颤合并冠心病PCI术后的患者选择何种抗凝和抗血小板药物联合一直是临床研究的热点。有一项针对房颤合并稳定性冠心病的队列研究表明,华法林联用双重抗血小板药物治疗,并不能明显的减少心肌梗死和(或)冠心病死亡和血栓栓塞事件,却显著增加出血风险。而在急性冠脉综合症患者中,三联抗血栓能够减少心血管死亡、心肌梗死和卒中事件,但是出血事件也明显增加,故其治疗利弊还存在争议。缺乏前瞻性临床研究证据,仅根据观察性研究和专家意见, 现有的部分国际指南和中国专家共识建议给予口服抗凝药物联合双联抗血小板药物。 

  2010年欧洲心脏病学学会(ESC)指南推荐房颤患者PCI术后置人裸金属支架患者三联抗栓至少1个月,雷帕霉素洗脱支架者三联抗栓应用华林;对ACS患者三联抗栓3—6个月。指南同时指出,应尽量避免应用药物洗脱支架,除非考虑到临床或血管病变的原因。ACCP9指南的建议为:1)、CHADS 2评分≧2分的心房颤动患者植入BMS 1个月内、植入DES 3~6个月内,建议应用华法林、阿司匹林、氯吡格雷三联抗栓治疗,此后应用华法林联合一种抗血小板药(阿司匹林或氯吡格雷)治疗。 若病情稳定,1年后则按照稳定型冠心病伴心房颤动的抗凝治疗原则仅应用华法林单药治疗。2)、CHADS 2 评分0 ~1分者建议在支架植入后1年内接受阿司匹林与氯吡格雷治疗,无需进行三联抗栓治疗,1年后若病情稳定则参照稳定型冠心病伴心房颤动的治疗原则进行抗凝治疗。以上所有指南的推荐均为C级证据。
 
  2013年发表在《Lancet》上的WOEST试验是一项比较接受PCI患者双联和三联抗栓治疗的一项前中心随机对照研究,结果显示,华法林+氯吡格雷优于焕发林+阿司匹林+氯吡格雷,双联抗栓组较三联抗栓组出血事件发生率明显降低,并且双联抗栓并未增加支架血栓(1.4%vs3.2%,P=0.165)、卒中(1.1%vs2.8%,P=0.128)和心肌梗死(3.2%vs4.6%,P=0.382)等缺血性事件的发生率。但是WOEST试验存在一些重要的问题限制了试验结论可靠性:总病例数少,随访时间短,只有69%的患者因房颤接受了口服抗凝治疗,大多数患者(70%–75%)接受了择期PCI,经股动脉通路占74%,局部出血增加。尽管WOEST试验存在很多的缺陷,但为华法林+氯吡格雷的二联抗栓策略的有效性和安全性提供了有力证据。 

四、新型抗凝药的运用 

  大量临床研究表明,与华法林相比,新型口服抗凝药物能够明显降低房颤抗栓治疗出血的风险。虽然有部分临床研究例如ATLAS-ADS2-TIM 51试验表明,双联抗血小板治疗基础上加用利伐 他班可减少ACS患者的心血管死亡、心肌梗死及卒中事件,但同时亦增加出血风险,患者总体获益不明显。但是对比WOEST试验的实验结果,利伐他班联用氯吡格雷,理论上会比华法林+氯吡格雷带来更大的临床获益,但尚需随机对照试验进一步评价。 

五、结论

  对房颤合并冠心病PCI的患者选择抗栓治疗方案之前应充分评估其血栓栓塞、支架血栓和出血风险,在出血高危患者使用质子泵抑制剂降低消化道出血发生率。三联抗栓时会使得患者出血风险增加,因而应密切监测抗凝强度。其对于对房颤合并冠心病PCI的患者尚无明确的定论,尚需更多的临床研究来为最优抗栓方案提供更为充分的循证医学证据。

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    2017-09-02 gujh
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    2017-03-28 qindq
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    2017-01-03 huangzh898

    学习了。别的部位的支架术后抗凝治疗也可以效仿吗?

    0

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