Раннее прекращение двойной антитромбоцитарной терапии за счет отмены ацетилсалициловой кислоты у больных с острым коронарным синдромом, подвергнутых чрескожным коронарным вмешательствам, как удачный подход к обеспечению геморрагической безопасности лечения

Ранние чрескожные коронарные вмешательства (ЧКВ) и достаточно длительное агрессивное антитромботическое лечение, основой которого является двойная антитромбоцитарная терапия (ДАТТ), являются важнейшими элементами лечения больных с острым коронарным синдромом (ОКС). Наиболее изучено и традиционно рекомендуется при ОКС годичное применение ДАТТ в виде сочетания ацетилсалициловой кислоты (АСК) и блокатора P2Y₁₂ рецепторов тромбоцитов. Геморрагические осложнения ДАТТ после ОКС и после ЧКВ, особенно заметные при использовании мощных блокаторов P2Y₁₂ рецепторов тромбоцитов, заставили искать подходы, направленные на снижение риска таких осложнений. Одним из недавно обозначенных решений проблемы высокого риска кровотечений при ЧКВ и ОКС оказалась достаточно ранняя (через 1-3 мес. от начала лечения) отмена АСК с продолжением приема одного антиагреганта — блокатора P2Y₁₂ рецепторов тромбоцитов. В аналитической статье приводятся факты и доводы, оправдывающие этот подход к изменению ДАТТ у больных с ОКС и/или ЧКВ.

1. Yusuf S, Zhao F, Mehta SR, et al. Effects of clopidogrel in addition to aspirin in patients with acute coronary syndromes without ST-segment elevation. N Engl J Med. 2001;345(7):494-502. doi:10.1056/NEJMoa010746.

2. Wiviott SD, Braunwald E, McCabe CH, et al. Prasugrel versus clopidogrel in patients with acute coronary syndromes. N Engl J Med. 2007;357(20):2001-15. doi:10.1056/NEJMoa0706482.

3. Wallentin L, Becker RC, Budaj A, et al. Ticagrelor versus clopidogrel in patients with acute coronary syndromes. N Engl J Med. 2009;361(11):1045-57. doi:10.1056/NEJMoa0904327.

4. 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):1082-115. doi:10.1016/j.jacc.2016.03.513.

5. Valgimigli M, Bueno H, Byrne RA, et al; ESC Scientific Document Group; ESC Committee for Practice Guidelines (CPG); ESC National Cardiac Societies. 2017 ESC focused update on dual antiplatelet therapy in coronary artery disease developed in collaboration with EACTS: the task force for dual antiplatelet therapy in coronary artery disease of the European Society of Cardiology (ESC) and of the European Association for Cardio-Thoracic Surgery (EACTS). Eur Heart J. 2018;39(3):213-60. doi:10.1093/eurheartj/ehx419.

6. 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):1298-1310. doi:10.1016/j.jacc.2015.01.039.

7. Palmerini T, Benedetto U, Bacchi-Reggiani L, et al. Mortality in patients treated with extended duration dual antiplatelet therapy after drug-eluting stent implantation: a pairwise and Bayesian network meta-analysis of randomised trials. Lancet. 2015;385(9985):2371-82. doi:10.1016/S0140-6736(15)60263-X.

8. Yin SH, Xu P, Wang B, et al. Duration of dual antiplatelet therapy after percutaneous coronary intervention with drug-eluting stent: systematic review and network metaanalysis. BMJ. 2019;365:2222. doi:10.1136/bmj.l2222.

9. Benenati S, Galli M, De Marzo V, et al. Very Short vs. Long Dual Antiplatelet Therapy after Second Generation Drug-eluting Stents in 35,785 Patients undergoing Percutaneous Coronary Interventions: A Meta-analysis of Randomised Controlled Trials. Eur. Heart J. Cardiovasc. Pharmacother. 2020:pvaa001. doi:10.1093/ehjcvp/pvaa001.

10. Capodanno D, Gargiulo G, Buccheri S, et al. Meta-analyses of dual antiplatelet therapy following drug-eluting stent implantation: do bleeding and stent thrombosis weigh similar on mortality? J Am Coll Cardiol. 2015;66(14):1639-1640. doi:10.1016/j.jacc.2015.05.085.

11. Cuisset T, Deharo P, Quilici J, et al. Benefit of switching dual antiplatelet therapy after acute coronary syndrome: the TOPIC (Timing Of Platelet Inhibition After Acute Coronary Syndrome) randomized study. Eur Heart J. 2017;38(41):3070-3078. doi:10.1093/eurheartj/ehx175.

12. Deharo P, Quilici J, Camoin-Jau L, et al. Benefit of switching dual antiplatelet therapy after acute coronary syndrome according to on-treatment platelet reactivity: the TOPIC-VASP pre-specified analysis of the TOPIC randomized study. JACC Cardiovasc Interv. 2017;10(24):2560-2570. doi:10.1016/j.jcin.2017.08.044.

13. Sibbing D, Aradi D, Jacobshagen C, et al. Guided de-escalation of antiplatelet treatment in patients with acute coronary syndrome undergoing percutaneous coronary intervention (TROPICAL-ACS): a randomised, open-label, multicentre trial. Lancet. 2017;390:1747-57. doi:10.1016/S0140-6736(17)32155-4.

14. 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. doi:10.1056/NEJMoa1908419.

15. Mehran R, Rao SV, Bhatt DL, et al. Standardized bleeding definitions for cardiovascular clinical trials: a consensus report from the bleeding academic research consortium. Circulation. 2011;123(23):2736-47. doi:10.1161/CIRCULATIONAHA.110.009449.

16. Armstrong PC, Leadbeater PD, Chan MV, et al. In the presence of strong P2Y12 receptor blockade, aspirin provides little additional inhibition of platelet aggregation. J Thromb Haemost. 2011;9:552-61. doi:10.1111/j.1538-7836.2010.04160.x.

17. Leadbeater PDM, Kirkby NS, Thomas S, et al. Aspirin has little additional anti-platelet effect in healthy volunteers receiving prasugrel. J Thromb Haemost. 2011;9:2050-6. doi:10.1111/j.1538-7836.2011.04450.x.

18. Vranckx P, Valgimigli M, Juni P, et al; GLOBAL LEADERS Investigators. Ticagrelor plus aspirin for 1 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 drug-eluting stent: a multicentre, open-label, randomised superiority trial. Lancet. 2018;392(10151):940-949. doi:10.1016/S0140-6736(18)31858-0.

19. Watanabe H, Domei T, Morimoto T, et al; STOPDAPT-2 Investigators. Effect 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. doi:10.1001/jama.2019.8145.

20. Hahn JY, Song YB, Oh JH, et al; SMART-CHOICE Investigators. Effect of P2Y12 Inhibitor Monotherapy vs Dual Antiplatelet Therapy on Cardiovascular Events in Patients Undergoing Percutaneous Coronary Intervention: The SMART-CHOICE Randomized Clinical Trial. JAMA. 2019;321(24):2428-2437. doi:10.1001/jama.2019.8146.

21. Kim C, Hong SJ, Shin DH, et al. Randomized evaluation of ticagrelor monotherapy after 3-month dual-antiplatelet therapy in patients with acute coronary syndrome treated with new-generation sirolimus-eluting stents: TICO trial rationale and design. Am Heart J. 2019;212:45-52. doi:10.1016/j.ahj.2019.02.015.

22. Kim B, Hong S, Cho Y, et al. Effect of Ticagrelor Monotherapy vs Ticagrelor With Aspirin on Major Bleeding and Cardiovascular Events in Patients With Acute Coronary Syndrome: The TICO Randomized Clinical Trial. JAMA. 2020;323(23):2407-16. doi:10.1001/jama.2020.7580.

23. Guedeney P, Mesnier J, Sorrentino S, et al. Early Aspirin Discontinuation Following Acute Coronary Syndrome or Percutaneous Coronary Intervention: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. J Clin Med. 2020;9(3):680. doi:10.3390/jcm9030680.

24. McClure JD, Ramsay JC, Berry C. Pooled Analysis of Bleeding, Major Adverse Cardiovascular Events, and All-Cause Mortality in Clinical Trials of Time-Constrained Dual-Antiplatelet Therapy After Percutaneous Coronary Intervention. J Am Heart Assoc. 2020;9(16):e017109. doi:10.1161/JAHA.120.017109.

25. O’Donoghue ML, Murphy SA, Sabatine MS. The Safety and Efficacy of Aspirin Discontinuation on a Background of a P2Y12 Inhibitor in Patients After Percutaneous Coronary Intervention: A Systematic Review and Meta-Analysis. Circulation. 2020;142(6):538-545. doi:10.1161/CIRCULATIONAHA.120.046251.

26. Giacoppo D, Matsuda Y, Fovino LN, et al. Short dual antiplatelet therapy followed by P2Y12 inhibitor monotherapy vs. prolonged dual antiplatelet therapy after percutaneous coronary intervention with second-generation drug-eluting stents: a systematic review and meta-analysis of randomized clinical trials. Eur Heart J. 2020:ehaa739. doi:10.1093/eurheartj/ehaa739.

27. Wiebe J, Ndrepepa G, Kufner S, et al. Early Aspirin Discontinuation After Coronary Stenting: A Systematic Review and Meta-Analysis. J Am Heart Assoc. 2021;10(2):e018304. doi:10.1161/JAHA.120.018304.

28. Kogame N, Guimaraes PO, Modolo R, et al. Aspirin-Free Prasugrel Monotherapy Following Coronary Artery Stenting in Patients With Stable CAD: The ASET Pilot Study. JACC Cardiovasc Interv. 2020;13(19):2251-62. doi:10.1016/j.jcin.2020.06.023.