吴智健,周志鹏,吴延庆

• 1:南昌大学第二附属医院心血管内科

摘要(Abstract)：

阿司匹林联合P2Y12抑制剂的双联抗血小板治疗是支架置入术的基石。双联抗血小板治疗能够减少血栓形成风险,但同时也会增加出血风险。针对支架置入术后最佳的双联抗血小板治疗疗程仍存在争议。本文通过回顾国内外的研究、指南共识,综述了关于双联抗血小板治疗的研究结果、影响因素和指南建议,认为应针对不同人群血栓形成和出血风险定制个体化双联抗血小板治疗策略。一般来说,短程的双联抗血小板治疗可考虑用于缺血低风险且出血高风险的患者,而长程双联抗血小板治疗则可考虑用于缺血高风险且出血低风险的患者。

关键词(KeyWords)： 冠状动脉粥样硬化性心脏病;经皮冠状动脉介入治疗;冠状动脉支架置入术;双联抗血小板治疗

Abstract:

Keywords:

基金项目(Foundation): 国家基金·地区科学基金项目（81660062）

作者(Author): 吴智健,周志鹏,吴延庆

参考文献(References)：

• [1]Levine GN,Bates ER,Bittl JA,et al.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):1082-1115.
• [2]Valgimigli M,Bueno H,Byrne RA,et al.2017 ESC focused update on dual antiplatelet therapy in coronary artery disease developed in collaboration with EACTS.Kardiol Pol,2017,75(12):1217-1299.
• [3]国家卫生计生委合理用药专家委员会，中国药师协会.冠心病合理用药指南（第2版）.中国医学前沿杂志（电子版），2018,10(6):1-130.
• [4]Collet JP,Silvain J,Barthélémy O,et al.Dual-antiplatelet treatment beyond 1 year after drug-eluting stent implantation (ARCTIC-Interruption):a randomised trial.Lancet,2014,384(9954):1577-1585.
• [5]Bittl JA,Baber U,Bradley SM,et al.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.Circulation,2016,134(10):e156-e178.
• [6]Navarese EP,Andreotti F,Schulze V,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.
• [7]Mauri L,Kereiakes DJ,Yeh RW,et al.Twelve or 30 months of dual antiplatelet therapy after drug-eluting stents.N Engl J Med,2014,371(23):2155-2166.
• [8]Hermiller JB,Krucoff MW,Kereiakes DJ,et al.Benefi ts and risks of extended dual antiplatelet therapy after everolimus-eluting stents.JACC Cardiovasc Interv,2016,9(2):138-147.
• [9]Helft G,Steg PG,Le Feuvre C,et al.Stopping or continuing clopidogrel 12 months af ter drug-eluting stent placement:the OPTIDUAL randomized trial.Eur Heart J,2016,37(4):365-374.
• [10]Gilard M,Barragan P,Noryani AAL,et al.6-versus 24-month dual antiplatelet therapy after implantation of drug-eluting stents in patients nonresistant to aspirin:the randomized,multicenter ITALIC trial.J Am Coll Cardiol,2015,65(8):777-786.
• [11]Park SJ,Park DW,Kim YH,et al.Duration of dual antiplatelet therapy after implantation of drug-eluting stents.N Engl J Med,2010,362(15):1374-1382.
• [12]Hong SJ,Shin DH,Kim JS,et al.6-Month versus 12-month dual-antiplatelet therapy f ollowing long everolimus-eluting stent implantation:the IVUS-XPL randomized clinical trial.JACCCardiovasc Interv,2016,9(14):1438-1446.
• [13]Furlan S,Borzak S.After PCI with 2nd-generation DESs for STEMI,dual-antiplatelet therapy for 6 mo was noninferior to 12 mo.Ann Intern Med,2019,170(2):JC6.
• [14]Feres F,Costa RA,Abizaid A,et al.Three vs twelve months of dual antiplatelet therapy after zotarolimus-eluting stents.JAMA,2013,310(23):2510-2522.
• [15]Schulz-Schüpke S,Byrne RA,Ten Berg JM,et al.ISAR-SAFE:a randomized,double-blind,placebo-controlled trial of 6 vs.12months of clopidogrel therapy after drug-eluting stenting.Eur Heart J,2015,36(20):1252-1263.
• [16]Colombo A,Chieff o A,Frasheri A,et al.Second-generation drugeluting stent implantation followed by 6-versus 12-month dual antiplatelet therapy:the SECURITY randomized clinical trial.J Am Coll Cardiol,2014,64(20):2086-2097.
• [17]Kim BK,Hong MK,Shin DH,et al.A new strategy for discontinuation of dual antiplatelet therapy:the RESET trial (real safety and efficacy of 3-month dual antiplatelet therapy following endeavor zotarolimus-eluting stent implantation).J Am Coll Cardiol,2012,60(15):1340-1348.
• [18]Gwon HC,Hahn JY,Park KW,et al.Six-month versus 12-month dual antiplatelet therapy after implantation of drug-eluting stents:the efficacy of xience/promus versus cypher to reduce late loss after stenting (EXCELLENT) randomized,multicenter study.Circulation,2012,125(3):505-513.
• [19]Mehran R,Baber U,Sharma SK,et al.Ticagrelor with or without aspirin in high-risk patients after PCI.N Engl J Med,2019,381(21):2032-2042.
• [20]Watanabe H,Domei T,Morimoto T,et al.Eff ect of 1-month dual antiplatelet therapy followed by clopidogrel vs 12-month dual antiplatelet therapy on cardiovascular and bleeding events in patients receiving PCI:the STOPDAPT-2 randomized clinical trial.JAMA,2019,321(24):2414-2427.
• [21]Vranckx P,Valgimigli M,Jüni P,et al.Ticagrelor plus aspirin for1 month,followed by ticagrelor monotherapy for 23 months vs aspirin plus clopidogrel or ticagrelor for 12 months,followed by aspirin monotherapy for 12 months after implantation of a drugeluting stent:a multicentre,open-label,randomised superiority trial.Lancet,2018,392(10151):940-949.
• [22]Koskinas KC,Ughi GJ,Windecker S,et al.Intracoronary imaging of coronary atherosclerosis:validation for diagnosis,prognosis and treatment.Eur Heart J,2016,37(6):524-35a-c.
• [23]Zhang YJ,Pang S,Chen XY,et al.Comparison of intravascular ultrasound guided versus angiography guided drug eluting stent implantation:a systematic review and meta-analysis.BMCCardiovasc Disord,2015,15:153.
• [24]Hong SJ,Kim BK,Shin DH,et al.Effect of intravascular ultrasound-guided vs.angiography-guided everolimus-eluting stent implantation:the IVUS-XPL randomized clinical trial.JAMA,2015,314(20):2155-2163.
• [25]Galassi AR,Sumitsuji S,Boukhris M,et al.Utility of intravascular ultrasound in percutaneous revascularization of chronic total occlusions:an overview.JACC Cardiovasc Interv,2016,9(19):1979-1991.
• [26]Iliescu CA,Cilingiroglu M,Giza DE,et al."Bringing on the light"in a complex clinical scenario:optical coherence tomographyguided discontinuation of antiplatelet therapy in cancer patients with coronary artery disease (PROTECT-OCT registry).Am Heart J,2017,194:83-91.
• [27]Meneveau N,Souteyrand G,Motreff P,et al.Optical coherence tomography to optimize results of percutaneous coronary intervention in patients with non-ST-elevation acute coronary syndrome:results of the multicenter,randomized DOCTORS study (does optical coherence tomography optimize results of stenting).Circulation,2016,134(13):906-917.
• [28]Stone GW,Ellis SG,Cannon L,et al.Comparison of a polymerbased paclitaxel-eluting stent with a bare metal stent in patients with complex coronary artery disease:a randomized controlled trial.JAMA,2005,294(10):1215-1223.
• [29]Camenzind E,Steg PG,Wijns W.Stent thrombosis late after implantation of first-generation drug-eluting stents:a cause for concern.Circulation,2007,115(11):1440-1455.
• [30]Joner M,Finn AV,Farb A,et al.Pathology of drug-eluting stents in humans:delayed healing and late thrombotic risk.J Am Coll Cardiol,2006,48(1):193-202.
• [31]Virmani R,Guagliumi G,Farb A,et al.Localized hypersensitivity and late coronary thrombosis secondary to a sirolimus-eluting stent:should we be cautious?Circulation,2004,109(6):701-705.
• [32]Palmerini T,Biondi-Zoccai G,Riva DD,et al.Stent thrombosis with drug-eluting and bare-metal stents:evidence from a comprehensive network meta-analysis.Lancet,2012,379(9824):1393-1402.
• [33]Otsuka F,Vorpahl M,Nakano M,et al.Pathology of secondgeneration everolimus-eluting stents versus fi rst-generation sirolimusand paclitaxel-eluting stents in humans.Circulation,2014,129(2):211-223.
• [34]Finn AV,Joner M,Nakazawa G,et al.Pathological correlates of late drug-eluting stent thrombosis:strut coverage as a marker of endothelialization.Circulation,2007,115(18):2435-2441.
• [35]Liberati A,Altman DG,Tetzlaff J,et al.The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate healthcare interventions:explanation and elaboration.BMJ,2009,339:b2700.
• [36]Giustino G,Chieff o A,Palmerini T,et al.Effi cacy and safety of dual antiplatelet therapy after complex PCI.J Am Coll Cardiol,2016,68(17):1851-1864.
• [37]Subhaharan D,Mridha N,Singh K.Clinical benefi ts of prolonged dual antiplatelet therapy following complex percutaneous coronary intervention.Coron Artery Dis,2020,31(3):273-278.
• [38]Piccolo R,Giustino G,Mehran R,et al.Stable coronary artery disease:revascularisation and invasive strategies.Lancet,2015,386(9994):702-713.
• [39]Giustino G,Baber U,Sartori S,et al.Duration of dual antiplatelet therapy after drug-eluting stent implantation:a systematic review and meta-analysis of randomized controlled trials.J Am Coll Cardiol,2015,65(13):1298-310.
• [40]Serruys PW,Takahashi K,Chichareon P,et al.Impact of longterm ticagrelor monotherapy following 1-month dual antiplatelet therapy in patients who underwent complex percutaneous coronary intervention:insights from the global leaders trial.Eur Heart J,2019,40(31):2595-2604.
• [41]Floyd CN,Ferro A.Antiplatelet drug resistance:molecular insights and clinical implications.Prostaglandins Other Lipid Mediat,2015,120:21-27.
• [42]Greer DM.Aspirin and antiplatelet agent resistance:implications for prevention of secondary stroke.CNS Drugs,2010,24(12):1027-1040.
• [43]关绍义，韩雅玲，李毅，等.强化抗血小板治疗对冠状动脉支架术后血小板高反应性的影响.中华心血管病杂志，2012,40(1):25-29.
• [44]Levine GN,Bates ER,Blankenship JC,et al.2011 ACCF/AHA/SCAI guideline for percutaneous coronary intervention:a report of the American College of Cardiology Foundation/American Heart Association task force on practice guidelines and the society for cardiovascular angiography and interventions.Circulation,2011,124(23):e574-e651.
• [45]Fihn SD,Gardin JM,Abrams J,et al.2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS guideline for the diagnosis and management of patients with stable ischemic heart disease:a report of the American College of Cardiology Foundation/American Heart Association task force on practice guidelines,and the American College of Physicians,American Association for Thoracic Surgery,Preventive Cardiovascular Nurses Association,Society for Cardiovascular Angiography and Interventions,and Society of Thoracic Surgeons.Circulation,2012,126(25):e354-e471.
• [46]O'Gara PT,Kushner FG,Ascheim DD,et al.2013 ACCF/AHAguideline for the management of ST-elevation myocardial infarction:a report of the American College of Cardiology Foundation/American Heart Association task force on practice guidelines.Circulation,2013,127(4):e362-e425.
• [47]Amsterdam EA,Wenger NK,Brindis RG,et al.2014 AHA/ACCguideline for the management of patients with non-ST-elevation acute coronary syndromes:executive summary:a report of the American College of Cardiology/American Heart Association task force on practice guidelines.Circulation,2014,130(25):2354-2394.