目前心房顫動患者合併抗血小板藥物和抗凝血劑治療的醫學證據

Update in the Combination of Antiplatelet and Antithrombotic Therapy in Atrial Fibrillation

黃天祈(Tien-Chi Huang) ； 林宗憲(Tsung-Hsien Lin) ； 溫文才(Wen-Chol Voon) ； 賴文德(Wen-Ter Lai) ； 許勝雄(Sheng-Hsiung Sheu)

《內科學誌》 25卷6期 (2014/12) Pp. 381-388

https://doi.org/10.6314/JIMT.2014.25(6).01

摘要

心房顫動患者中風機會、中風嚴重度都比無心房顫動的患者來得高，歐洲心臟學會2010年以及美國心臟學會2014年的指引，一致建議針對非瓣膜性心房顫動患者使用CHA2DS2-VASc score來評估中風危險的程度，若大於等於2分則需要使用抗凝血劑治療。然而心房顫動患者合併有冠狀動脈疾病者不少見，若曾接受經皮冠狀動脈介入性治療或發生心肌梗塞，必須合併使用抗血小板藥物，因此會增加患者出血的風險，然則若減少其中一種藥物則可能增加患者血管再栓塞的危險。本篇參考美國和歐洲的心房顫動指引，其中2014年美國心房顫動指引建議心房顫動且CHA2DS2-VASc score≧2的患者若有接受冠狀動脈疾病的治療，應使用clopidogrel和口服Vitamin K抗凝血劑，而aspirin則不建議。至於新一代抗凝血劑如何搭配抗血小板藥物使用，目前美國和歐洲指引都沒有給予明確的建議和搭配方式。另外PIONEER AF-PCI和RE-DUAL試驗正在進行中，希望能給予我們更清楚的答案。

關鍵字

心房顫動 ； 抗血小板藥物 ； 抗凝血劑

並列摘要

The possibility and severity of stroke in patients with atrial fibrillation are higher than those without atrial fibrillation. Both European Society of Cardiology (ESC) and American Heart Association (AHA) guidelines recommend the CHA_2DS_2-VASc score to evaluate the risk of stroke for patients with the non-valvular atrial fibrillation. If the score is greater than or equal to 2 points, we should prescribe anticoagulant therapy. However, patients with atrial fibrillation and coronary artery disease are not uncommon. If they had ever received percutaneous coronary stenting or had a history of acute coronary syndrome, the guideline would suggest to combine two antiplatelet agents with anticoagulant which would increase the risk of bleeding. Discontinuation of one of 3 drugs may increase the risk of vascular thrombosis. The guideline favors the combination of clopidogrel and oral vitamin K antagonist in patients with CHA_2DS_2-VASc score ≧ 2 and coronary artery disease. As for how to combine the new oral anticoagulants with antiplatelet agents, the current AHA and ESC guidelines do not give clear recommendations. The ongoing PIONEER AF-PCI and RE-DUAL trials will answer the questions.

並列關鍵字

Atrial fibrillation ； Antiplatelet agents ； Anticoagulant