А.С. Рудой
Учреждение образования «Белорусский государственный медицинский университет», Минск, Беларусь
В обзорной статье представлены современные данные по одному из ключевых вопросов современной кардиологии — продолжительности двойной антитромбоцитарной терапии у пациентов с перенесенным острым коронарным синдромом, в том числе после коронарной ангиопластики. Проведен анализ актуальных клинических рекомендаций (в том числе ESC72017 по двойной антиагрегантной терапии и остром коронарном синдроме с подъемом сегмента ST), освещены результаты недавних клинических исследований и проведенных метаанализов. Учитывая дилемму балансирования между рисками тромбоэмболических событий и осложнений кровотечения у данных пациентов, представлена шкала оценки рисков ишемических и геморрагических событий, сформированная по результатам исследований DAPT и PRECISE7DAPT.
ключевые слова: двойная антитромбоцитарная терапия, продолжительность, ацетилсалициловая кислота, тиенопиридины, иш емические события, кровотечения, чрескожное коронарное вмешательство, острый коронарный синдром

для цитирования: А.С. Рудой. Эволюция взглядов на антитромбоцитарную терапию при остром коронарном синдроме. Неотложная кардиология и кардиоваскулярные риски. 2018, Т. 2. № 2. С. 462-437

Evolving views on antithrombotic therapy in acute coronary syndrome
A.S. Rudoy
The review article presents current data on one of the key issues of modern cardiology - the duration of dual antiplatelet therapy in patients with acute coronary syndrome, including postcoronary angioplasty. The analysis of current clinical recommendations (including ESC-2017 for dual antiplatelet therapy and acute coronary syndrome with ST segment elevation) was carried out, the results of recent clinical studies and meta-analyzes were high-lighted. Given the dilemma of balancing the risks of thrombotic events and complications of bleeding in these patients, a scale for assessing the risks of ischemic and hemorrhagic events, formed on the basis of the results of the DAPT and PRECISE-DAPT studies, is presented.
keywords: dual antiplatelet therapy, duration, acetylsalicylic acid, thienopyridine, ischemic events, bleeding, percutaneous coronary intervention, acute coronary syndrome

for references: A.S. Rudoy. Evolving Views on Antithrombotic Therapy in Acute Coronary Syndrome. Emergency Cardiology and C ardiovascularRisks. 2018, vol. 2, № 2, pp. 462-437

[1] Yaman Al.F. Population division department of economic and social affairs United Nations MORTPAK for windows version 4.0. J Popul Res, 2004, Nov., [4] p.
[2] Schomig A., Neumann F.J., Kastrati A., Schuhlen H., Blasini R., Hadamitzky M., Walter H., Zitzmann-Roth E.M., Richardt G., Alt E., Schmitt C., Ulm K. A randomized comparison of antiplatelet and anticoagulant therapy after the placement of coronaryartery stents. N Engl J Med, 1996, vol. 334, № 17, pp. 1084–1089. doi: 10,1056 / NEJM199604253341702.
[3] Valgimigli M., Bueno H., Byrne R.A., Collet J.P., Costa F., Jeppsson A., J ni P., Kastrati A., Kolh P., Mauri L., Montalescot G., Neumann F.J., Petricevic M., Roffi M., Steg P.G., Windecker S., Zamorano J.L. Special article 2017 ESC focused update on dual antiplatelet therapy in coronary artery disease developed in collaboration with EACTS. Rev Esp Cardiol (Engl Ed), 2018, vol. 71, № 1, pp. 42. doi: 10.1016/j.rec.2017.11.020.
[4] McFadden E.P., Stabile E., Regar E., Cheneau E., Ong A.T. Kinnaird T.,Suddath W.O., Weissman N.J., Torguson R., Kent K.M., Pichard A.D.,Satler L.F., Waksman R., Serruys P.W.. Late thrombosis in drugeluting coronary stents after discontinuation of antiplatelet therapy. Lancet, 2004, vol. 364, № 9444, pp. 1519–1521. doi: 10.1016/S01406736(04)172759.
[5] Antman E.M., Cohen M., Bernink P.J., McCabe C.H., Horacek T., Papuchis G., Mautner B., Corbalan R., Radley D., Braunwald E. The TIMI risk score for unstable angina/nonST elevation MI: A method for prognostication and therapeutic decision making. JAMA, 2000, vol. 284, № 835–842. PMID: 10938178.
[6] Fox K.A., Dabbous O.H., Goldberg R.J., Pieper K.S., Eagle K.A., Van de Werf F.,Avezum A., Goodman S.G., Flather M.D., Anderson F.A. Jr., Granger C.B. Prediction of risk of death and myocardial infarction in the six months after presentation with acute coronary syndrome: prospective multinational observational study (GRACE). BMJ, 2006, vol. 333, № 7578, pp. 1091.doi: 10,1136 / bmj.38985.646481.55.
[7] Subherwal S., Bach R.G., Chen A.Y., Gage B.F., Rao S.V., Newby L.K., Wang T.Y, Gibler W.B., Ohman E.M., Roe M.T., Pollack C.V. Jr., Peterson E.D., Alexander K.P. Baseline risk of major bleeding in non-ST-segment elevation myocardial infarction: the CRUSADE (Can Rapid risk stratification of Unstable angina patients Suppress ADverse outcomes with Early implementation of the ACC/AHA Guidelines) bleeding score. Circulation, 2009, vol. 119, № 14, pp. 1873–1882. doi: 10,1161 / Circulationaha. 108.828541.
[8] Mehran R., Pocock S.J., Nikolsky E, Clayton T., Dangas G.D., Kirtane A.J., Parise H., Fahy M., Manoukian S.V., Feit F., Ohman M.E., Witzenbichler B., Guagliumi G., Lansky A.J., Stone G.W. A risk score to predict bleeding in patients with acute coronary syndromes. J Am Coll Cardiol, 2010, vol. 55, № 23, pp. 2556–2566. doi: 10.1016 / j.jacc.2009.09.076.
[9] Mathews R., Peterson E.D., Chen A.Y., Wang T.Y., Chin C.T., Fonarow G.C., Cannon C.P., Rumsfeld J.S., Roe M.T., Alexander K.P. Inhospital major bleeding during STelevation and non-ST-elevation myocardial infarction care: derivation and validation of a model from the ACTION Registry(R)-GWTG.Am J Cardiol, 2011, vol. 107, № 8, pp. 1136–1143. doi: 10.1016 / j.amjcard.2010.
[10] Valgimigli M., Costa F., Byrne R., Haude M., Baumbach A., Windecker S. Dual antiplatelet therapy duration after coronary stenting in clinical practice: results of an EAPCI survey. EuroIntervention, 2015, vol. 11, № 1, pp. 68–74. doi: 10.4244 / EIJV11I1A11.
[11] Borja I., Agewall S., James S., Widimsky P. 2017 ESC Guidelines for the management of acute myocardial infarction in patients presenting with STsegment elevation: The Task Force for the management of acute myocardial infarction in patients presenting with STsegment elevation of the European Society of Cardiology (ESC). European heart J, 2017, vol. 39, № 2, pp. 119–177. doi: 10.1093 / eurheartj / ehx393.
[12] Bonaca M.P., Bhatt D., Braunwald E., Cohen M., Steg P.G. Storey R.F., Held P.,Jensen E.C., Sabatine M.S. Design and rationale for the prevention of cardiovascular events in patients with prior heart attack using ticagrelor compared to placebo on a background of aspirinthrombolysis in myocardialinfarction 54 (PEGASUSTIMI 54) trial. Am Heart J, 2014, vol. 167, № 4, pp. 437–444.e5. doi: 10.1016 / j.ahj.2013.12.020.
[13] Bagai A., Bhatt D.L., Eikelboom J.W., John Mancini G.B., Cohen E.A., Ram Vijayaraghavan, Cheema A.N., Udell J.A., Niznick J., Tanguay J.F., Verma S.,Shamir R.M. Individualizing Duration of Dual Antiplatelet Therapy After Acute Coronary Syndrome or Percutaneous Coronary Intervention. Circulation, 2016, vol. 133, pp. 2094–2098. doi: 10.1161/circulationaha. 115.021158.
[14] Mauri L., Kereiakes D.J., Yeh R.W., DriscollShempp P., Cutlip D.E., Steg P.G., Normand S.L., Braunwald E., Wiviott S.D., Cohen D.J., Holmes D.R.Jr. Twelve or 30 months of dual antiplatelet therapy after drug eluting stents. N Engl J Med, 2014, vol. 371, № 23, pp. 2155–2166. doi: 10.1056/NEJMoa1409312.
[15] Yeh R.W., Secemsky E.A., Kereiakes D.J., Normand S.L., Gershlick A.H., Cohen D.J., Spertus J.A., Steg P.G., Cutlip D.E., Rinaldi M.J., Camenzind E.,Wijns W., Apruzzese P.K., Song Y., Massaro J.M., Mauri L. Development and validation of a prediction rule for benefit and harm of dual antiplatelet therapy beyond 1 year after percutaneous coronary intervention. JAMA, 2016, vol. 315, № 16, pp.1735–1749. doi: 10.1001 / jama.2016.3775.
[16] Mehran R., Baber U., Steg P.G., Ariti C., Weisz G., Witzenbichler B., Henry T.D., Kini A.S., Stuckey T., Cohen D.J., Berger P.B., Iakovou I., Dangas G., Waksman R., Antoniucci D., Sartori S., Krucoff M.W., Hermiller J.B., Shawl F., Gibson C.M., Chieffo A., Alu M., Moliterno D.J., Colombo A., Pocock S. Cessation of dual antiplatelet treatment and cardiac events after percutaneous coronary intervention (PARIS): 2 year results from a prospective observational study. Lancet, 2013, vol. 382, № 9906, pp. 1714–1722. doi: 10.1016 / S01406736 (13) 61720-1.
[17] Baber U., Mehran R., Giustino G., Cohen D.J., Henry T.D., Sartori S., Ariti C., Litherland C., Dangas G., Gibson C.M., Krucoff M.W., Moliterno D.J., Kirtane A.J.,Stone G.W., Colombo A., Chieffo A., Kini A.S., Witzenbichler B., Weisz G.,Steg P.G., Pocock S. Coronary thrombosis and major bleeding after PCI with drugeluting stents: risk scores from PARIS. J Am Coll Cardiol, 2016, vol. 67, № 19, pp. 2224–2234. doi: 10.1016 / j.jacc. 2016.02.064.
[18] Bhatt D.L., Flather M.D., Hacke W., Berger P.B., Black H.R., Boden W.E.,Cacoub P., Cohen E.A., Creager M.A., Easton J.D., Hamm C.W., Hankey G.J.,Johnston S.C., Mak K.H., Mas J.L., Montalescot G., Pearson T.A., Steg P.G.,Steinhubl S.R., Weber M.A., FabryRibaudo L., Hu T., Topol E.J., Fox K.A. Patients with prior myocardial infarction, stroke, or symptomatic peripheral arterial disease in the CHARISMA trial. J Am Coll Cardiol, 2007, vol.49, № 19, pp. 1982–1988. doi: 10,1016 / j.jacc.2007.03.025.
[19] Steinhubl S.R., Berger P.B., Mann J.T. Fry E.T., DeLago A., Wilmer C., Topol E.J.Early and sustained dual oral antiplatelet therapy following percutaneous coronary intervention: a randomized controlled trial. JAMA, 2002, vol. 288, № 19, pp. 2411–2420. PMID: 12435254.
[20] Costa F., van Klaveren D., James S., Heg D., Raber L., Feres F., Pilgrim T.,Hong M.K., Kim H.S., Colombo A., Steg P.G., Zanchin T., Palmerini T., Wallentin L., Bhatt D.L., Stone G.W., Windecker S., Steyerberg E.W., Valgimigli M. Derivation and validation of the predicting bleeding complications in patients undergoing stent implantation and subsequent dual antiplatelet therapy (PRECISE-DAPT) score: a pooled analysis of individualpatient datasets from clinical trials. Lancet, 2017, vol. 389, № 10073, pp. 1025–1034. doi:10.1016 / S01406736 (17) 303975.
[21] Koskinas K.C., Raber L., Zanchin T., Wenaweser P., Stortecky S., Moschovitis A., Khattab A.A., Pilgrim T., Blochlinger S., Moro C., Juni P., Meier B.,Heg D., Windecker S. Clinical impact of gastrointestinal bleeding in patients undergoing percutaneous coronary interventions. Circ Cardiovasc Interv, 2015, vol. 8, № 5, pp. e002053. doi: 10.1161/ CIRCINTERVENTIONS.114.002053.
[22] Wallentin L., Becker R.C., Budaj A., Cannon C.P., Emanuelsson H., Held C., Horrow J., Husted S., James S., Katus H., Mahaffey K.W., Scirica B.M., Skene A., Steg PG, Storey RF, Harrington R.A. Ticagrelor versus clopidogrel in patients with acute coronary syndromes. N Engl J Med. 2009, vol. 361, № 11, pp. 1045–1057. doi: 10.1056 / NEJMoa0904327.
[23] Aboyans V., Ricco J.B., Bartelink M.L.E., Bj rck M., Brodmann M., Cohnert T.,Collet J.P., Czerny M., De Carlo M., Debus S. 2017 ESC Guidelines on the Diagnosis and Treatment of Peripheral Arterial Diseases, in collaboration with the European Society for Vascular Surgery (ESVS) Document covering atherosclerotic disease of extracranial carotid and vertebral, mesenteric, renal, upper and lower extremity arteries. Endorsed by: the European Stroke Organization (ESO). The Task Force for the Diagnosis and Treatment of Peripheral Arterial Diseases of the European Society of Cardiology (ESC) and of the European Society for Vascular Surgery (ESVS). Eur Heart J, 2018, vol. 39, № 9, pp. 763–816. doi: 10.1093/eurheartj/ehx095.
[24] Yeh R.W., Kereiakes D.J., Steg P.G., Windecker S., Rinaldi M.J., Gershlick A.H., Cutlip D.E., Cohen D.J., Tanguay J.F., Jacobs A., Wiviott S.D., Massaro J.M., Iancu AC, Mauri L. Benefits and risks of extended duration dual antiplatelet therapy after PCI in patients with and without acute myocardial infarction. J Am Coll Cardiol, 2015, vol. 65, № 20, pp. 2211–2221. doi: 10.1016/j.jacc.2015.03.003.
[25] Wiviott S.D., White H.D., Ohman E.M., Fox K.A., Armstrong P.W., Prabhakaran D., Hafley G., Lokhnygina Y., Boden W.E., Hamm C., Clemmensen P.,Nicolau J.C., Menozzi A., Ruzyllo W., Widimsky P., Oto A., Leiva-Pons J.,Pavlides G., Winters K.J., Roe M.T., Bhatt D.L. Prasugrel versus clopidogrel for patients with unstable angina or nonSTsegment elevation myocardial infarction with or without angiography: a secondary, prespecified analysis of the TRILOGY ACS trial. Lancet, 2013, vol. 382, № 9892, pp. 605–613.doi: 10.1016 / S01406736 (13) 61451-8.
[26] Scirica B.M., Bonaca M.P., Braunwald E., De Ferrari G.M., Isaza D., Lewis B.S., Mehrhof F., Merlini P.A., Murphy S.A., Sabatine M.S., Tendera M., Van de Werf F., Wilcox R., Morrow D.A. Vorapaxar for secondary prevention of thrombotic events for patients with previous myocardial infarction: a prespecified subgroup analysis of the TRA 2_PTIMI 50 trial. Lancet, 2012, vol. 380, № 9850, pp. 1317–1324. doi: http://dx.doi.org/10.1016/S01406736(12)612690.
[27] Udell J.A., Bonaca M.P., Collet J.P., Lincoff A.M., Kereiakes D.J., Costa F.,Lee C.W., Mauri L., Valgimigli M., Park S.J., Montalescot G., Sabatine M.S., Braunwald E., Bhatt D.L. Long-term dual antiplatelet therapy for secondary prevention of cardiovascular events in the subgroup of patients with previous myocardial infarction: a collaborative meta-analysis of randomized trials. Eur Heart J, 2016, vol. 37, № 4, pp. 390–399. doi: 10.1093 / eurheartj / ehv443.
[28] Costa F., Adamo M., Ariotti S., Navarese E.P., Biondi-Zoccai G., Valgimigli M.Impact of greater than 12-month dual antiplatelet therapy duration on mortality: drugspecific or a class-effect? A meta-analysis. Int J Cardiol, 2015, vol. 201, pp. 179–181. doi: 10.1016 / j.ijcard.2015.08.058.
[29] Palmerini T., Della Riva D., Benedetto U., Bacchi Reggiani L., Feres F.,Abizaid A., Gilard M., Morice M.C., Valgimigli M., Hong M.K., Kim B.K., Jang Y., Kim H.S., Park K.W., Colombo A., Chieffo A., Sangiorgi D., Biondi Zoccai G., G n reux P., Angelini G.D., Pufulete M., White J., Bhatt D.L., Stone G.W. Three, six or twelve months of dual antiplatelet therapy after drugeluting stent implantation in patients with or without acute coronary syndromes: an individual patient data pairwise and network metaanalysis of six randomized trials and 11 473 patients. Eur Heart J, 2017, vol. 38, № 14, pp. 1034–1043. doi: 10.1093 / eurheartj / ehw627.
[30] Urban P., Meredith I.T, Abizaid A., Pocock S.J., Carrie D.., Naber C, Lipiecki J., Richardt G., Iniguez A., Brunel P., ValdesChavarri M., Garot P., Talwar S., Berland J., Abdellaoui M., Eberli F., Oldroyd K., Zambahari R., Gregson J., Greene S., Stoll H.P., Morice M.C. Polymerfree drugcoated coronary stents in patients at high bleeding risk. N Engl J Med, 2015, vol. 373, № 21, pp. 2038–2047. doi: 10.1056 / NEJMoa1503943.
[31] Valgimigli M., Patialiakas A., Thury A., McFadden E., Colangelo S., Campo G., Tebaldi M., Ungi I., Tondi S., Roffi M., Menozzi A., de Cesare N., Garbo R., Meliga E., Testa L., Gabriel H.M., Airoldi F., Ferlini M., Liistro F., Dellavalle A., Vranckx P., Briguori C. Zotarolimuseluting versus baremetal stents in uncertain drugeluting stent candidates. J Am Coll Cardiol, 2015, vol. 65, № 8, pp. 805–815. doi: 10.1016 / j.jacc.2014.11.053.
[32] Bueno H., FernandezAviles F. Use of risk scores in acute coronary syndromes. Heart, 2012, vol. 98, № 2, pp. 162–168. doi:10.1136/heartjnl 2011300129.
Формат файла: pdf (946.02 Кб)