EuroPCR 2015：双联抗血小板治疗时间到底延长还是缩短？

2015-05-29 中国医学科学院阜外医院颜红兵中国医学论坛报

争鸣缘何而起？2015年欧洲血运重建大会（EuroPCR 2015）于5月19日在法国巴黎揭幕，开幕式后的重头戏是75分钟有关“日常实践中的双联抗血小板治疗（DAPT）”的辩论争鸣。其背景是过去5年先后发表了12项有关DAPT时间的研究结果，包括PRODIGY研究、EXCELLENT研究、OPTIMIZE研究、RESET研究、ITALIC研究、DES-LATE研究、ZEST-LATE研究、REAL

争鸣缘何而起？

2015年欧洲血运重建大会（EuroPCR 2015）于5月19日在法国巴黎揭幕，开幕式后的重头戏是75分钟有关“日常实践中的双联抗血小板治疗（DAPT）”的辩论争鸣。其背景是过去5年先后发表了12项有关DAPT时间的研究结果，包括PRODIGY研究、EXCELLENT研究、OPTIMIZE研究、RESET研究、ITALIC研究、DES-LATE研究、ZEST-LATE研究、REAL-LATE研究、ARCTIC-Interruption研究、DAPT研究、TL-PAS研究和Pegasus研究，以及2014年8月30日欧洲心脏病学会（ESC）与欧洲心胸外科学会（EACTS）在线发表的2014心肌血运重建治疗指南。

以4个病例为基础的讨论

这次“日常实践中的DAPT”争鸣是以4个病例为基础，分别假设了4种临床情况下的双联抗血小板治疗时间：①稳定的冠状动脉疾病，冠脉介入治疗效果良好；②非ST段抬高型心肌梗死，置入多个药物洗脱支架；③非ST段抬高型心肌梗死、高龄女性患者，低体重，肾功能受损；④急性冠脉综合征合并心房颤动。

临床研究证据回顾

回顾过去发表的相关研究，有5项重要研究支持缩短DAPT时间。2项是6个月DAPT与24个月DAPT比较，2项是3个月与12个月比较，1项是6个月与12个月比较。结果显示，3个月或6个月与12个月或24个月比较，主要终点事件没有显著性差异，而1项研究显示24个月DAPT增加出血事件。研究还显示，药物洗脱支架（DES）的种类和是否合并糖尿病，可能与包括支架内血栓在内的主要终点事件增加有关。

还有5项研究比较了12个月DAPT与16～30个月DAPT，2项研究显示延长DAPT时间并不降低主要终点，反而有增加心肌梗死、卒中或全因死亡率或出血的趋势。另2项研究显示延长DAPT可以降低包括支架内血栓在内的主要终点，但是其中1项研究提示增加出血，而另1项研究显示并不增加出血。

以患者为中心成为共识

这次辩论争鸣得到的基本共识是DAPT时间要以患者为中心。DAPT时间可以缩短为6个月的前提条件是：①应用新一代DES；②稳定性冠状动脉疾病择期PCI；③有发生出血的高风险。

延长DAPT可以减少冠状动脉血栓性事件的发生，但延长治疗并没有带来死亡率的降低。其中可能的原因包括：①延长DAPT增加出血事件；②入选患者的风险程度不一致，急性冠脉综合征（ACS）患者的血栓风险显著高于稳定性冠心病患者，这两类患者延长DAPT时间的获益可能存在差异；③终止DAPT后3个月血栓性事件均有升高，提示冠状动脉血栓性事件可能是动态的连续过程，现有临床研究DAPT时间可能远不能覆盖疾病的整个病程。

总之，临床实践中DAPT的最佳时间并不清楚，需要考虑冠状动脉疾病的性质（稳定性冠心病还是ACS）、支架种类（老一代DES还是新一代DES）、PCI的复杂性（简单手术还是复杂手术）和患者的具体风险（缺血与出血）来决策（即个体化治疗）。

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2016-03-22 tomyang98

#EuroPCR#

79 0
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2015-11-14 ms306040998833292

#治疗时间#

75 0
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2016-02-02 tulenzi

#双联抗血小板#

64 0
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2015-06-28 owlhealth

亚组分析

175 0
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2015-05-31 huaxipanxing

看看

204 0
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2015-05-30 Tommy1950

#PCR#

71 0
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2015-05-30 12498bf3m28暂无昵称

#双联抗血小板治疗#

69 0
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2015-05-30 lovetcm

在不同的人群中，可能应该有不同疗程，半年一年还是更长时间应该个体化决策

132 0
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2015-05-30 hbwang006

要长

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EuroPCR 2015：双联抗血小板治疗时间到底延长还是缩短？

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