Тикагрелор у пациентов с острым коронарным синдромом без подъемов ST и консервативной стратегией лечения - Научно-практический журнал Cardioсоматика Том 7, №1 (2016)

Тикагрелор у пациентов с острым коронарным синдромом без подъемов ST и консервативной стратегией лечения

Эрлих А.Д. Тикагрелор у пациентов с острым коронарным синдромом без подъемов ST и консервативной стратегией лечения. КардиоСоматика. 2016; 7 (1): 51–55.

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Erlikh A.D. Ticagrelor in patients with acute coronary syndrome without ST elevation and a conservative treatment strategy. Сardiosomatics. 2016; 7 (1): 51–55.

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Аннотация

Статья посвящена обзору актуальности использования двойной антитромбоцитарной терапии (ДАТ) у пациентов с острым коронарным синдромом (ОКС) без подъемов ST (ОКСбпST), получающих консервативное лечение. В сравнении с теми больными с ОКСбпST, которым проводилось чрескожное коронарное вмешательство, консервативно леченные пациенты традиционно имеют больше сопутствующих заболеваний, факторов риска и худший прогноз. Именно у этой подгруппы больных для улучшения исходов наиболее актуально проводить максимально правильное лечение ОКС, наиболее строго соответствующее современным клиническим руководствам. В первую очередь это касается той терапии, с помощью которой можно попытаться воздействовать на механизм развития ОКС, а именно антитромбоцитарной терапии. Результаты клинического исследования PLATO показали, что использование в качестве ДАТ сочетания ацетилсалициловой кислоты (АСК) и тикагрелора связано с уменьшением частоты развития сердечно-сосудистой смерти, инфаркта или инсульта (первичные неблагоприятные события) по сравнению с сочетанием АСК и клопидогрела. Результаты дополнительного анализа исследования PLATO показали, что при сравнении групп пациентов с ОКСбпST, леченных инвазивно и консервативно, отмечалось сходное пропорциональное снижение частоты первичных неблагоприятных событий при использовании тикагрелора по сравнению с группой применения клопидогрела (отношение риска 0,86 по сравнению с 0,85; значение р для взаимодействия 0,89), что не противоречит общим результатам исследования. Среди пациентов с ОКСбпST, лечившихся консервативно, прием тикагрелора по сравнению с приемом клопидогрела был связан с достоверно меньшим количеством развития любых смертельных исходов (относительный риск 0,73; 95% доверительный интервал 0,57–0,93). Частота развития «больших» кровотечений среди консервативно леченных пациентов с ОКСбпST, получавших тикагрелор и клопидогрел, достоверно не различалась. Результаты исследования PLATO определили обязательное использование тикагрелора в качестве ДАТ у больных с ОКСбпST независимо от выбранной стратегии лечения.

Ключевые слова: острый коронарный синдром, тикагрелор, консервативная стратегия, исходы.

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The article provides an overview of the relevance of the use of dual antiplatelet therapy (DAT) in patients with acute coronary syndrome (ACS) without lifting ST (ACSwlST) receiving conservative treatment. Compared with those patients with ACSwlST who underwent percutaneous coronary intervention, conservative treatment, patients traditionally have more comorbidities, risk factors and prognosis is worse. It is in this subgroup of patients to improve outcomes most important to carry out the most correct treatment of ACS, most strictly corresponding to current clinical guidelines. In particular this applies to that therapy, with which you can try to influence the mechanism of development of ACS, namely antirombocit therapy. The results of a clinical study PLATO showed that the use as a DAT combination with acetylsalicylic acid (ASA) and ticagrelor due to a decrease in the incidence of cardiovascular death, heart attack or stroke (primary adverse events) as compared to the combination of ASA and clopidogrel. The results of further analysis of PLATO study showed that when comparing the groups of patients with ACSwlST treatment of invasive and conservative, noted a similar proportional reduction in the incidence of primary adverse events when using ticagrelor compared to clopidogrel group (hazard ratio of 0.86 compared with 0.85; p-value for interaction 0.89), which is consistent with the overall results of the study. Among patients with ACSwlST treated conservatively, receiving ticagrelor as compared with clopidogrel was associated with a significantly smaller number of all deaths (relative risk, 0.73; 95 CI 0.57–0.93). The frequency of the "big" bleeding among patients treated conservatively with ACSwlST treated with ticagrelor and clopidogrel did not differ significantly. PLATO study results identified the mandatory use of ticagrelor as DAT in patients with ACSwlST regardless of the chosen treatment strategy.

Key words: acute coronary syndrome, ticagrelor, conservative strategy, outcomes.

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Список литературы

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________________________________________________

1. Roger VL, Go AS, Lloyd-Jones DM et al. Executive summary: heart disease and stroke statistics—2012 update: a report from the American Heart Association. Circulation 2012; 125: 188–97.
2. Ellis C, Gamble G, Devlin G et al. The management of acute coronary syndrome patients across New Zeland in 2012: results of a third comprehensive nationwide audit and observations of current interventional care. N Z Med J 2013; 126 (1387): 36–68.
3. Puymirat E, Schiele F, Steg PG et al. Determinants of improved one-year survival in non-ST-segment elevation myocardial infarction patients: insights from the French FAST-MI program over 15 years. Int J Cardiol 2014; 177 (1): 281–6.
4. Reibis R, Voller H, Gitt A et al. Management of Patients With ST-Segment Elevation or Non-ST-Segment Elevation Acute Coronary Syndromes in Cardiac Rehabilitation Centers. Clin Cardiol 2014; 37 (4): 213–21.
5. Erlikh A.D., Gratsianskii N.A. ot imeni uchastnikov registra REKORD. Registr ostrykh koronarnykh sindromov REKORD. Kharakteristika bol'nykh i lechenie do vypiski iz statsionara. Kardiologiia. 2009; 7: 4–12. [in Russian]
6. Bhatt IL, Roe MT, Peterson ED et al. Utilization of early invasive management strategies for high-risk patients with non-ST-segment elevation acute coronary syndromes: results from the CRUSADE Quality Improvement Initiative. JAMA 2004; 292: 2096–104.
7. Chan MY, Mahaffey KW, Sun LJ et al. Prevalence, Predictors, and Impact of Conservative Medical Management for Patients With Non-ST-Segment Elevation Acute Coronary Syndromes Who Have Angiographically Documented Significant Coronary Disease. JACC 2008; 1 (4): 369–78.
8. O'Donoghue M, Boden WE, Braunwald E et al. Early invasive vs conservative treatment strategies in women and men with unstable angina and non-ST-segment elevation myocardial infarction: a meta-analysis. JAMA 2008; 300 (1): 71–80.
9. Bavry AA, Kumbhani DJ, Rassi AN et al. Benefit of early invasive therapy in acute coronary syndromes: a meta-analysis of contemporary randomized clinical trials. J Am Coll Cardiol 2006; 48:1319.
10. Hansen KW, Sorensen R, Madsen M et al. Effectiveness of an early versus a conservative invasive treatment strategy in acute coronary syndromes: a nationwide cohort study. Ann Intern Med 2015; 163: 737.
11. Maddox TM, Ho PM, Tsai TT et al. Clopidogrel Use and Hospital Quality in Medically Managed Patients With Non-ST-Segment-Elevation Myocardial Infarction. Circulation: Cardiovasc Quality and Outcomes 2012; 5: 523–31.
12. Jancin B. Medically treated NSTEACS patients “forgotten”. Cardiol News 2007.
13. Libby P. Current concepts of pathogenesis of the acute coronary syndromes. Circulation 2001; 104: 365–72.
14. ISIS-2 collaborative group. Randomised trial of intravenous streptokinase, oral aspirin, both, or nether among 17187 cases of suspected acute myocardial infarction: ISIS-2. Lancet 1988; 332 (8607): 349–60.
15. The Clopidogrel in Unstable Angina to Prevent Recurrent Events Trial Investigators. Effects of Clopidogrel in Addition to Aspirin in Patients with Acute Coronary Syndromes without ST-Segment Elevation. N Engl J Med 2001; 345: 494–502.
16. 2014 AHA/ACC Guideline for the Management of Patients With Nonз-ST-Elevation Acute Coronary Syndromes A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. JACC 2014; 64 (24): e139-e228.
17. ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation. Eur Heart J 2015. Doi: 10.1093/eurheartj/ehv320.
18. Wiviott SD, Braunwald E, McCabe CH et al. For the TRITON-TIMI 38 Investigators. Prasugrel versus Clopidogrel in Patients with Acute Coronary Syndromes. N Engl J Med 2007; 357: 2001–15.
19. Bhatt DL, Stone GW, Mahaffey KW et al. For the CHAMPION PHOENIX Investigators Effect of Platelet Inhibition with Cangrelorduring PCI on Ischemic Events. N Engl J Med 2013; 368: 1303–13.
20. James S et al. Poster #1353 Presented at the European Society of Cardiology, Stockholm, Sweden, 28 August-1 September 2010.
21. Lindholm D, Varenhorst C, Cannon CP et al. Ticagrelor vs. clopidogrel in patients with non-ST-elevation acute coronary syndrome with or without revascularization: results from the PLATO trial. Eur Heart J 2014; 35 (31): 2083–93.

Авторы

А.Д.Эрлих

ГБУЗ Городская клиническая больница №29 им. Н.Э.Баумана Департамента здравоохранения г. Москвы. 111020, Россия, Москва, Госпитальная пл., д. 2;
ФГБУН НИИ физико-химической медицины ФМБА России. 119435, Россия, Москва, ул. Малая Пироговская, д. 1а
alexeyerlikh@gmail.com

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A.D.Erlikh

N.E.Bauman City Clinical Hospital №29. 111020, Russian Federation, Moscow, Gospital'naya pl., d. 2;
Institute of Physico-Chemical Medicine of Russia. 119435, Russian Federation, Moscow, ul. Malaya Pirogovskaya, d. 1a;
alexeyerlikh@gmail.com

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