Обзор американских кардиологических журналов за неделю (ссылки)

[Chevychelov]

Title: Antithrombotic Management of Atrial Fibrillation Patients Presenting with Acute Coronary Syndrome and/or Undergoing Coronary Stenting: Executive Summary—A Consensus Document of the European Society of Cardiology Working Group on Thrombosis, Endorsed by the European Heart Rhythm Association (EHRA) and the European Association of Percutaneous Cardiovascular Interventions (EAPCI)
Topic: Interventional Cardiology
Date Posted: 5/12/2010
Author(s): Lip GY, Huber K, Andreotti F, et al.
Citation: Eur Heart J 2010;May 6:[Epub ahead of print].
Clinical Trial: No
Perspective: The following are 10 points to remember from this consensus document:

1. Approximately 70-80% of patients with atrial fibrillation (AF) have an indication for oral anticoagulation therapy (OAT). Coronary artery disease co-exists in 20-30% of these patients.

2. Patients with AF on OAT are often bridged with unfractionated heparin or low molecular weight heparin if they need coronary angiography or percutaneous coronary intervention (PCI). Use of bridging therapy is associated with increased risk of access site complications in some studies. Some observational studies suggest that coronary angiography or PCI can be safely performed without interrupting OAT, and may be associated with a lower rate of complications compared with bridging therapy.

3. In small series, the rate of complications in patients on OAT who undergo angiography or PCI via the femoral route has been low. However, the radial route should be preferred in patients on OAT.

4. There is no need for additional heparin in patients who undergo PCI while therapeutic on OAT (international normalized ratio [INR] 2-3).

5. Aspirin and clopidogrel should be administered prior to the procedure when PCI is performed in a patient on OAT.

6. The use of platelet glycoprotein IIb/IIIa inhibitors increases the risk of bleeding in patients on OAT 3- to 13-fold and the routine use of these agents should be avoided in patients on OAT.

7. Use of aspirin and warfarin does not provide sufficient protection against risk of stent thrombosis. Patients undergoing stent-based PCI should be treated with triple therapy consisting of aspirin, clopidogrel, and warfarin. This combination is associated with an increased risk of bleeding, and use of bare-metal stents should be considered in these patients to limit the duration of triple therapy.

8. In patients who need long-term OAT, use of drug-eluting stents should be restricted to patients at very high risk of restenosis (long lesions, small vessels, diabetes). Alternative therapies (coronary artery bypass grafting [CABG], medical therapy, bare-metal stents) should be considered before implanting drug-eluting stents in a patient who needs long-term OAT.

9. In patients on triple therapy, closer monitoring of INR targeted to 2.0-2.5 and use of proton pump inhibitors may help reduce the risk of bleeding.

10. There are limited data on safety of cardiac surgery in patients who are on OAT. Currently, these patients are bridged with heparin prior to surgery. In the event of need for emergent CABG in a patient on OAT, fresh frozen plasma and vitamin K may be used to reverse OAT and reduce the risk of bleeding. Hitinder S. Gurm, M.B.B.S., F.A.C.C.