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.
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