双联抗血小板药物治疗在DES置入后一年证明是有效的

Dual Antiplatelet Therapy Efficacious One Year Post-DES

一项探讨术后一年是否应给予双联抗血小板药物的争论，最终趋于一致：无禁忌症的患者应该无限期地进行抗血小板治疗。

杜克大学John L.Petesen教授推荐在置入DES后，进行一年以上的治疗甚至在多数患者中进行永久治疗。

“我趋于同意对手的观点”哥伦比亚大学Antonio Colombo教授说，“没有支持定期治疗的证据。在这时，我建议只要是DES置入应继续进行抗血小板治疗。这种方法可能不会阻止晚期支架血栓的发生，如果发生的话，你不能因此责怪双联抗血小板治疗。”

支架血栓发生较为罕见

Colombo争论说，支架血栓比较罕见，及时没有双联抗血小板治疗。在STARS研究中，患者分组给予阿司匹林和ticlopidine，他们30天事件率低（MI，血栓，TLR和死亡），低于给予华法林和阿司匹林或阿司匹林单药（P=0.001）。但是，以这项试验为例，Colombo说，12个连续患者能服用阿司匹林单药而不发生支架血栓。

“即使患者置入罗支架，也可从双联抗血小板药物收益，所以为什么我们不给所有患者给予该疗法呢？”Colombo说。出血风险是“硬币的另一面，可能是唯一可确定的事实。”

CAD的治疗

Petesen争论道，双重抗血小板治疗对于CAD患者疗效更显著。从PCI-CURE试验中得出的长期结果，从试验开始时的随机分组到后来的随访，均显示氯吡格雷和阿司匹林（8.8%）比安慰剂加阿司匹林（12.6%）的患者低。

在CAPRIE类似的队列组中，Petesen说，先前发生MI的患者给予氯吡格雷加阿司匹林，其主要终点MI、中风和心脑血管死亡及缺血或周围血管疾病（7.3%）均低于安慰剂加阿司匹林患者（8.8%；P=0.01）。

新技术如光学干涉断层成像技术，将会使人更好地了解DES和裸金属支架的生物学（如内皮化），因此可以得出更多确切答案，但是“我认为你需要保守治疗，使人们持续进行双联抗血小板治疗。”Petesen说。

（《医心评论》编辑 刘瑞琦 翻译 马秀芹 校对）

（来源：www.tctmd.com）

Dual Antiplatelet Therapy Efficacious One Year Post-DES 

Key Points:

Experts advise continuing therapy for as long as possible.

By TCT Daily Staff

What started as two presentations arguing for or against continuing dual antiplatelet therapy after one year ended with both sides in agreement: Patients without contraindications to therapy should continue it indefinitely.

John L. Petersen, MD, assistant professor of medicine in the division of cardiovascular medicine at Duke University Medical Center in Durham, N.C., said he recommends therapy longer than one year or even indefinitely in most patients after DES.

"I tend to agree with my opponent," said Antonio Colombo, MD, director of the cardiac cath lab at Columbus Hospital/San Raffaele Hospital in Milan, Italy. "There are no data to support any definite statement. At this time, I would advise to continue dual antiplatelet therapy for as long as possible following implantation of DES. Such an approach may not prevent late stent thrombosis, [and] in case it happens, you cannot blame dual antiplatelet therapy."

Stent thrombosis is rare

Colombo argued that stent thrombosis is rare, even without dual antiplatelet therapy. In the STARS study, patients assigned aspirin and ticlopidine had better 30-day event rates (MI, thrombus, TLR, and death) than patients assigned warfarin and aspirin or aspirin alone (P=.001). However, using this trial as an example, Colombo said that 12 consecutive patients could take aspirin alone and not have stent thrombosis.

"Even [patients with] bare-metal stents benefit from prolonged dual antiplatelet therapy, so why don’t we give it to everyone?" Colombo asked. The risk for bleeding is "the other side of the coin and it may be the only certainty."

Therapy for CAD

Petersen argued that the benefit of dual antiplatelet therapy is strong in patients with CAD. Overall long-term results from the PCI-CURE trial showed a lower rate of the composite of cardiovascular death or MI from time of randomization to end of follow-up among patients assigned clopidogrel and aspirin (8.8%) vs. those assigned placebo and aspirin (12.6%).

In a CAPRIE-like cohort, Petersen said, patients with previous MI who were assigned clopidogrel and aspirin had a lower rate of the primary endpoint of MI, stroke and CV death and ischemia or peripheral arterial disease (7.3%) than patients assigned placebo and aspirin (8.8%; P=.01).

New technologies such as optical coherence tomography will allow a better understanding of the biology of DES and bare-metal stents (ie, endothelialization), which may lead to more definitive answers, but "I think you have to be conservative and keep people on antiplatelet therapy," Petersen said.

Disclosures:

Dr. Petersen reports receiving research grants from Cordis Corporation, Edwards Lifesciences, Abbott Vascular, Schering Plough, Merck, The Medicines Company, and InfraReDx.
Dr. Colombo reports no relevant conflicts of interest.

（source：www.tctmd.com）