冠心病合并心房颤动患者抗凝治疗方案的选择

冠心病合并心房颤动患者抗凝治疗方案的选择前言无论中西方国家，冠心病和房颤都是致残、致死率位居前列的两大心血管疾病，二者在发展和转归上互为恶化，其并存将导致死亡风险加倍。大量的临床试验证据表明，冠心病依靠抗血小板药物减少心血管事件，房颤则依靠口服抗凝药物降低脑卒中等血栓栓塞事件。冠心病合并房颤的抗凝治疗难点在于这两类药物不能完全替代，而联用抗血小板和抗凝药物又面临着出血增加的风险。如何在取得最大获益的同时将出血风险降至最低，这是制定冠心病合并房颤抗凝治疗方案的关键。风险评估（ESC房颤指南）非瓣膜病房颤的血栓栓塞风险评估CHA2DS2-VASc出血风险评估HAS-BLED血栓栓塞风险评估CHA2DS2-VASc

(a)Riskfactorsforstrokeandthrombo-embolisminnon-valvularAF‘Major’riskfactors‘Clinicallyrelevantnon-major’riskfactorsHeartfailureormoderatetosevereLVsystolicdysfunctionHypertensionAge>75yearsDiabetesmellitusPreviousstroke,TIA,orsystemicembolismVasculardiseaseaAge65–74yearsFemalesex(b)Riskfactor-basedapproachexpressedasapointbasedscoringsystem,withtheacronymCHA2DS2-VASc(Note:maximumscoreis9sinceagemaycontribute0,1,or2points)血栓栓塞风险评估CHA2DS2-VASc

RiskfactorsScorsCongestiveheartfailure/LVdysfunction1Hypertension1Age>752Diabetesmellitus1Stroke/TIA/thrombo-embolism2Vasculardiseasea1Age65–741Sexcategory(i.e.femalesex)1Maximumscore9血栓栓塞风险评估CHA2DS2-VASc

RiskcategoryCHA2DS2-VAScscoreRecommendedantithrombotictherapyOne‘major’riskfactoror>2‘clinicallyrelevantnon-major’riskfactors>2OACOne‘clinicallyrelevantnon-major’riskfactor1EitherOACoraspirin75–325mgdaily.Preferred:OACratherthanaspirinNoriskfactors0Eitheraspirin75–325mgdailyornoantithrombotictherapy.Preferred:noantithrombotictherapyratherthanaspirin.出血风险评估HAS-BLED

LetterClinicalcharacteristicaPointsawardedHHypertension1AAbnormalrenalandliverfunction(1pointeach)1or2SStroke1BBleeding1LLabileINRs1EElderly(e.g.age>65years1DDrugsoralcohol(1pointeach)1or2Maximum9points冠心病合并房颤抗凝方案选择稳定冠心病急性冠脉综合征经皮冠状脉介入治疗围手术期冠脉旁路移植围手术期冠心病伴心衰稳定冠心病药物保守治疗者栓塞风险治疗方案选择高危VKA单药治疗，不建议加用阿司匹林INR2.0-3.0阿司匹林（75-150mg）+氯吡格雷75mg低危或中危伴出血风险阿司匹林（75-150mg）/氯吡格雷75mg稳定冠心病拟择期行PCI者高危避免DES，尽可能选择BMSBMSVKA+阿司匹林+氯吡格雷4周出血风险高者2-4周加用PPI后VKA单药终生INR2.0-3.0DES雷帕霉素三联3个月2.0-2.5紫杉醇三联6个月2.0-2.5后VKA+阿司匹林/波立维至术后12个月后VKA单药终生抗凝低中危低危者，无需VKA治疗，择期PCI依支架术常规抗凝方案VKA抗凝任何阶段均需密切监测INR及出血倾向急性冠脉