Поиск оптимального соотношения эффективности и безопасности при антитромбоцитарной терапии ишемической болезни сердца

Поиск оптимального соотношения эффективности и безопасности при антитромбоцитарной терапии ишемической болезни сердца

 1550

Поиск оптимального соотношения эффективности и безопасности при антитромбоцитарной терапии ишемической болезни сердца

Журнал "Медицинский совет. Кардиология" № 5, 2018


С.Г. Канорский, д.м.н., профессор, Кубанский государственный медицинский университет Минздрава России, Краснодар

Ацетилсалициловая кислота остается основой антитромбоцитарного лечения при стабильной ишемической болезни сердца (ИБС), в т. ч. после шунтирования коронарных артерий. Двойная антитромбоцитарная терапия (ДАТ), состоящая из ацетилсалициловой кислоты и ингибитора P2Y12-рецепторов (клопидогрел, прасугрел, тикагрелор), уменьшает риск рецидива основных ишемических осложнений у пациентов с острыми коронарными синдромами (ОКС) и/или подвергавшихся чрескожному коронарному вмешательству (ЧКВ), но неизбежно повышает риск больших кровотечений по сравнению с антитромбоцитарной монотерапией. Принцип индивидуализации лечения реализуется на основе оценки клинического статуса пациента (стабильная ИБС или ОКС), соотношения риска ишемических осложнений и кровотечения, стратегии ведения. В обзоре представлена доказательная база антитромбоцитарной терапии стабильной ИБС и ОКС при консервативном лечении и реваскуляризации миокарда, являющаяся основой положений действующих клинических рекомендаций. Оптимальная продолжительность ДАТ после ОКС и ЧКВ, согласно современным представлениям, может варьировать от 1 до 48 месяцев и продолжает изучаться в рандомизированных исследованиях. В самое последнее время формируется принцип деэскалации антитромбоцитарной терапии после ОКС и ЧКВ, развиваемый с учетом активно обсуждаемых результатов клинических проектов, опубликованных во второй половине 2017 г.

S.G. Kanorsky, MD, Prof., Kuban State Medical University of the Ministry of Health of Russia, Krasnodar

Search for an optimal efficacy-to-safety ratio for anti-platelet therapy of ischemic heart disease 

Acetylsalicylic acid remains the basis of anti-platelet therapy for stable ischemic heart disease (IHD), including conditino after coronary artery bypass grafting. Double anti-platelet therapy (APT) consisting of acetylsalicylic acid and a P2Y12 receptor inhibitor (clopidogrel, prasugrel, ticagrelor) reduces the risk of recurrence of major ischemic complications in patients with acute coronary syndromes (ACS) and/or those who underwent percutaneous coronary intervention (PCI), but inevitably increases the risk of major bleeding compared with anti-platelet monotherapy. The principle of personified treatment is implemented on the basis of an assessment of the patient’s clinical status (stable ischemic heart disease or ACS), the ratio of the ischemic and bleeding risks, strategies of management. The review presents the evidence-base to support anti-platelet therapy of stable IHD and ACS in conservative treatment and myocardial revascularization, which forms the basis of the current clinical guidelines. According to the current views the optimal duration of APT after ACS and PCI can vary from 1 to 48 months and continues to be studied in randomized trials. Most recently, the principle of de-escalation of anti-platelet therapy after ACS and PCI has been developed, taking into account the actively discussed findings of clinical projects published in the second half of 2017.

Поиск оптимального соотношения эффективности и безопасности при антитромбоцитарной терапии ишемической болезни сердца

Загрузить файл



Список литературы

1. Roth GA, Johnson C, Abajobir A, Abd-Allah F, Abera SF, Abyu G et al. Global, Regional, and National Burden of Cardiovascular Diseases for 10 Causes, 1990 to 2015. J Am Coll Cardiol, 2017, 70(1): 1-25.

2. Ibanez B, James S, Agewall S, Antunes MJ, Bucciarelli-Ducci C, Bueno H et al. 2017 ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation: The Task Force for the management of acute myocardial infarction in patients presenting with ST-segment elevation of the European Society of Cardiology (ESC). Eur Heart J, 2017 Aug 26. doi: 10.1093/eurheartj/ehx393.[Epub ahead of print].

3. Steg PG, Dorman SH, Amarenco P. Atherothrombosis and the role of antiplatelet therapy.J Thromb Haemost, 2011, 9(Suppl 1): 325-332.

4. Baigent C, Blackwell L, Collins R, Emberson J, Godwin J, Peto R et al. Aspirin in the primary and secondary prevention of vascular disease: collaborative meta-analysis of individual participant data from randomised trials. Lancet, 2009, 373(9678): 1849-1860.

5. Montalescot G, Sechtem U, Achenbach S, Andreotti F, Arden C, Budaj A et al. 2013 ESC guidelines on the management of stable coronary artery disease: the Task Force on the management of stable coronary artery disease of the European Society of Cardiology. Eur Heart J, 2013, 34(38): 2949-3003.

6. Roffi M, Patrono C, Collet JP, Mueller C, Valgimigli M, Andreotti F et al. 2015 ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation: Task Force for the Management of Acute Coronary Syndromes in Patients Presenting without Persistent ST-Segment Elevation of the European Society of Cardio logy (ESC). Eur Heart J, 2016, 37(3): 267-315.

7. Valgimigli M, Bueno H, Byrne RA, Collet JP, Costa F, Jeppsson A et al. 2017 ESC focused update on dual antiplatelet therapy in coronary artery disease developed in collaboration with EACTS: The Task Force for dual antiplatelet therapy in coronary artery disease of the European Society of Cardiology (ESC) and of the European Association for Cardio-Thoracic Surgery (EACTS). Eur Heart J, 2017 Aug 26. doi: 10.1093/eurheartj/ehx419. [Epub ahead of print].

8. CAPRIE Steering Committee. A randomised, blinded, trial of clopidogrel versus aspirin in patients at risk of ischaemic events (CAPRIE). CAPRIE Steering Committee. Lancet, 1996, 348(9038): 1329-1339.

9. Bhatt DL, Grosser T, Dong JF, Logan D, Jeske W, Angiolillo DJ et al. Enteric Coating and Aspirin Nonresponsiveness in Patients With Type 2 Diabetes Mellitus. J Am Coll Cardiol, 2017, 69(6): 603-612.

10. Bhatt DL, Fox KA, Hacke W, Berger PB, Black HR, Boden WE et al. Clopidogrel and aspirin versus aspirin alone for the prevention of atherothrombotic events. N Engl J Med, 2006, 354(16): 1706-1717.

11. Bhatt DL, Flather MD, Hacke W, Berger PB, Black HR, Boden WE et al. Patients with prior myocardial infarction, stroke, or symptomatic peripheral arterial disease in the CHARISMA trial. J Am Coll Cardiol, 2007, 49(19): 1982-1988.

12. Eikelboom JW, Connolly SJ, Bosch J, Dagenais GR, Hart RG, Shestakovska O et al. Rivaroxaban with or without Aspirin in Stable Cardiovascular Disease. N Engl J Med, 2017, 377(14): 1319-1330.

13. Palmerini T, Benedetto U, Bacchi-Reggiani L, Della Riva D, Biondi-Zoccai G, Feres F et al. Mortality in patients treated with extended duration dual antiplatelet therapy after drug-eluting stent implantation: a pairwise and Bayesian network meta-analysis of randomised trials. Lancet, 2015, 385(9985): 2371-2382.

14. Navarese EP, Andreotti F, Schulze V, Kołodziejczak M, Buffon A, Brouwer M et al. Optimal duration of dual antiplatelet therapy after percutaneous coronary intervention with drug eluting stents: meta-analysis of randomised controlled trials. BMJ, 2015, 350: h1618.

15. Giustino G, Baber U, Sartori S, Mehran R, Mastoris I, Kini AS et al. Duration of dual anti-platelet therapy after drug-eluting stent implantation: a systematic review and meta-analysis of randomized controlled trials. J Am Coll Cardiol, 2015, 65(13): 1298-1310.

16. Mauri L, Kereiakes DJ, Yeh RW, Driscoll-Shempp P, Cutlip DE, Steg PG et al. Twelve or 30 months of dual antiplatelet therapy after drug-eluting stents. N Engl J Med, 2014, 371(23): 2155-2166.

17. Bittl JA, Baber U, Bradley SM, Wijeysundera DN. Duration of Dual Antiplatelet Therapy: A Systematic Review for the 2016 ACC/AHA Guideline Focused Update on Duration of Dual Antiplatelet Therapy in Patients With Coronary Artery Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. J Am Coll Cardiol, 2016, 68(10): 1116-1139.

18. Palmerini T, Stone GW. Optimal duration of dual antiplatelet therapy after drug-eluting stent implantation: conceptual evolution based on emerging evidence. Eur Heart J, 2016, 37(4): 353-364.

19. Mehta SR, Bassand JP, Chrolavicius S, Diaz R, Eikelboom JW, Fox KA et al. Dose comparisons of clopidogrel and aspirin in acute coronary syndromes. N Engl J Med, 2010, 363(10): 930-942.

20. Berger JS. Aspirin, clopidogrel, and ticagrelor in acute coronary syndromes. Am J Cardiol, 2013, 112(5): 737-745.

21. Yusuf S, Zhao F, Mehta SR, Chrolavicius S, Tognoni G, Fox KK. Effects of clopidogrel in addition to aspirin in patients with acute coronary syndromes without ST-segment elevation. N Engl J Med, 2001, 345(7): 494-502.

22. James SK, Roe MT, Cannon CP, Cornel JH, Horrow J, Husted S et al. Ticagrelor versus clopidogrel in patients with acute coronary syndromes intended for non-invasive management: substudy from prospective randomised PLATelet inhibition and patient Outcomes (PLATO) trial. BMJ, 2011, 342: d3527.

23. Bonaca MP, Bhatt DL, Cohen M, Steg PG, Storey RF, Jensen EC et al. Long-term use of ticagrelor in patients with prior myocardial infarction.N Engl J Med, 2015, 372(19):1791-1800.

24. Mehta SR, Yusuf S, Peters RJ, Bertrand ME, Lewis BS, Natarajan MK et al. Effects of pretreatment with clopidogrel and aspirin followed by longterm therapy in patients undergoing percutaneous coronary intervention: the PCI-CURE study. Lancet, 2001, 358(9281): 527-533.

25. Wiviott SD, Braunwald E, McCabe CH, Montales-cot G, Ruzyllo W, Gottlieb S et al. Prasugrel versus clopidogrel in patients with acute coronary syndromes. N Engl J Med, 2007, 357(20): 2001-2015.

26. Wallentin L, Becker RC, Budaj A, Cannon CP, Emanuelsson H, Held C et al. Ticagrelor versus clopidogrel in patients with acute coronary syndromes. N Engl J Med, 2009, 361(11): 1045-1057.

27. Motovska Z, Hlinomaz O, Kala P, Hromadka M, Knot J, Varvarovsky I et al. One-year Outcomes of Prasugrel Versus Ticagrelor In Acute Myo cardial Infarction Treated With Primary Angio plasty: The PRAGUE-18 Study. J Am Coll Cardiol, 2017 Nov 9. pii: S0735-1097(17)41524-5. doi: 10.1016/j.jacc.2017.11.008. [Epub ahead of print].

28. Bonaca MP, Bhatt DL, Cohen M, Steg PG, Storey RF, Jensen EC et al. Long-term use of ticagrelor in patients with prior myocardial infarction.N Engl J Med, 2015, 372(19): 1791-1800.

29. Vogel B, Baber U. Antiplatelet treatments: recent evidence from randomized controlled trials. Curr Opin Cardiol, 2017, 32(4): 356-362.

30. Huber K, Ducrocq G, Hamm CW, van ‘t Hof A, Lapostolle F, Coste P et al. Early clinical outcomes as a function of use of newer oral P2Y12 inhibitors versus clopidogrel in the EUROMAX trial. Open Heart, 2017, 4(2): e000677.

31. Cuisset T, Deharo P, Quilici J, Johnson TW, Deffarges S, Bassez C et al. Benefit of switching dual antiplatelet therapy after acute coronary syndrome: the TOPIC (timing of platelet inhibition after acute coronary syndrome) randomi-zed study. Eur Heart J, 2017, 38(41): 3070-3078.

32. Deharo P, Quilici J, Camoin-Jau L, Johnson TW, Bassez C, Bonnet G et al. Benefit of Switching Dual Antiplatelet Therapy After Acute Coronary Syndrome According to On-Treatment Platelet Reactivity: The TOPIC-VASP Pre-Specified Analysis of the TOPIC Randomized Study.JACC Cardiovasc Interv, 2017, 10(24): 2560-2570.

33. Zocca P, van der Heijden LC, Kok MM, Löwik MM, Hartmann M, Stoel MG et al. Clopidogrel or ticagrelor in acute coronary syndrome patients treated with newer-generation drug-eluting stents: CHANGE DAPT. EuroIntervention, 2017, 13(10): 1168-1176.

34. Sibbing D, Aradi D, Jacobshagen C, Gross L, Trenk D, Geisler T et al. Guided de-escalation of antiplatelet treatment in patients with acute coronary syndrome undergoing percutaneous coronary intervention (TROPICAL-ACS): a randomised, open-label, multicentre trial. Lancet, 2017, 390(10104): 1747-1757.

35. Vranckx P, Valgimigli M, Windecker S, Steg PG, Hamm C, Jüni P et al. Long-term ticagrelor monotherapy versus standard dual antiplatelet therapy followed by aspirin monotherapy in patients undergoing biolimus-eluting stent implantation: rationale and design of the GLOBAL LEADERS trial. EuroIntervention, 2016, 12(10): 1239-1245.

36. Angiolillo DJ, Rollini F, Storey RF, Bhatt DL, James S, Schneider DJ et al. International Expert Consensus on Switching Platelet P2Y12 Receptor-Inhibiting Therapies. Circulation, 2017, 136(20): 1955-1975.




Кардиология