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Как улучшить антикоагулянтную терапию у пациента с фибрилляцией предсердий?
Кочетков А.И., Остроумова О.Д., Ляхова Н.Л., Буторов В.Н. Как улучшить антикоагулянтную терапию у пациента с фибрилляцией предсердий? Consilium Medicum. 2020; 22 (5): 40–48. DOI: 10.26442/20751753.2020.5.200151
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Kochetkov A.I., Ostroumova O.D., Lyakhova N.L., Butorov V.N. How to improve anticoagulant therapy in atrial fibrillation? Consilium Medicum. 2020; 22 (5): 40–48. DOI: 10.26442/20751753.2020.5.200151
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Аннотация
Фибрилляция предсердий (ФП) является важнейшим фактором риска развития инсульта, для профилактики которого при данном нарушении ритма пациентам показано назначение антикоагулянтной терапии. В настоящее время в ведущих клинических рекомендациях подчеркивается превосходство прямых оральных антикоагулянтов над антагонистами витамина K. Вместе с тем в клинической практике часто встречаются сложные ситуации, когда у пациентов существенно меняется риск ишемических осложнений и кровотечений, имеется бремя различных коморбидных заболеваний, нарушена функция почек и/или пациенту предстоит оперативное вмешательство, что значительно затрудняет выбор оптимальной стратегии антикоагулянтной терапии и конкретного препарата для ее реализации. Кроме того, в силу сложившихся неблагоприятных эпидемиологических условий нельзя не учитывать возможных эффектов новой коронавирусной инфекции на состояние пациентов с фибрилляцией предсердий. В таких сложных клинических случаях среди прямых оральных антикоагулянтов препаратом первого выбора является апиксабан благодаря наличию у него обширной доказательной базы (как по данным рандомизированных клинических исследований, так и по результатам исследований реальной клинической практики), подтверждающей оптимальный профиль эффективности и безопасности препарата у таких категорий больных.
Ключевые слова: фибрилляция предсердий, прямые оральные антикоагулянты, апиксабан, высокий риск инсульта/кровотечений, ишемическая болезнь сердца, хроническая болезнь почек, оперативные вмешательства, COVID-19.
Ключевые слова: фибрилляция предсердий, прямые оральные антикоагулянты, апиксабан, высокий риск инсульта/кровотечений, ишемическая болезнь сердца, хроническая болезнь почек, оперативные вмешательства, COVID-19.
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Atrial fibrillation is the most important risk factor for stroke, and as a preventive strategy in these patients anticoagulant therapy are must be prescribed. Currently, pivotal clinical guidelines emphasize the superiority of direct oral anticoagulants (DOACs) over vitamin K antagonists. At the same time, difficult cases in clinical practice are often encountered, patients’ risk of ischemic and bleeding events may significantly change, they also may have a burden of various comorbidities, impaired renal function and/or exposed to surgical intervention. These factors make it difficult to choose the optimal anticoagulant therapy strategy and prescribe optimal DOAC. Also, due to the prevailing adverse epidemiological conditions, it is impossible to ignore the potential effects of the new coronavirus infection on patients with atrial fibrillation. In such complex clinical cases, among the DOACs, the first choice drug is apixaban, due to its extensive body of evidence (both according to randomized clinical trials and real world data), which confirms the optimal efficacy and safety balance in above mentioned patients.
Key words: atrial fibrillation, direct oral anticoagulants, apixaban, clinical practice, high risk of stroke/bleeding, coronary artery disease, chronic kidney disease, surgical intervention, COVID-19.
Полный текст
Список литературы
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6. Fohtung RB, Rich MW. Identification of patients at risk of stroke from atrial fibrillation. US Cardiol Rev 2016; 10 (2): 60–4. DOI: 10.15420/usc.2016:1:1
7. Ушкалова Е.А., Зырянов С.К., Думченко Е.В. Подходы к антитромботической терапии у пациентов пожилого возраста c фибрилляцией предсердий. Рациональная фармакотерапия в кардиологии. 2017; 13 (2): 275–83. DOI: 10.20996/1819-6446-2017-13-2-275-283
[Ushkalova E.A., Zyryanov S.K., Dumchenko E.V. Approaches to Antithrombotic Therapy in Elderly Patients with Atrial Fibrillation. Rational Pharmacotherapy in Cardiology. 2017; 13 (2): 275–83. DOI: 10.20996/1819-6446-2017-13-2-275-283 (in Russian).]
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12. Halvorsen S, Atar D, Yang H et al. Efficacy and safety of apixaban compared with warfarin according to age for stroke prevention in atrial fibrillation: observations from the ARISTOTLE trial. Eur Heart J 2014; 35 (28): 1864–72. DOI: 10.1093/eurheartj/ehu046
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[Oganov R.G., Simanenkov V.I., Bakulin I.G. et al. Comorbidities in clinical practice. Algorithms for diagnostics and treatment. Cardiovascular Therapy and Prevention. 2019; 18 (1): 5–66. DOI: 10.15829/1728-8800-2019-1-5-66 (in Russian).]
17. Fox KAA, Velentgas P, Camm AJ et al. Outcomes Associated With Oral Anticoagulants Plus Antiplatelets in Patients With Newly Diagnosed Atrial Fibrillation. JAMA Netw Open 2020; 3 (2): e200107. DOI: 10.1001/jamanetworkopen.2020.0107
18. Gwyn JCV, Thomas MR, Kirchhof P. Triple antithrombotic therapy in patients with atrial fibrillation undergoing percutaneous coronary intervention: a viewpoint. Eur Heart J Cardiovasc Pharmacother 2017; 3 (3): 157–62. DOI: 10.1093/ehjcvp/pvx002
19. Lopes RD, Vora AN, Liaw D et al. An open-Label, 2 × 2 factorial, randomized controlled trial to evaluate the safety of apixaban vs. vitamin K antagonist and aspirin vs. placebo in patients with atrial fibrillation and acute coronary syndrome and/or percutaneous coronary intervention: Rationale and design of the AUGUSTUS trial. Am Heart J 2018; 200: 17–23. DOI: 10.1016/j.ahj.2018.03.001
20. Lopes RD, Heizer G, Aronson R et al.; AUGUSTUS Investigators. Antithrombotic Therapy after Acute Coronary Syndrome or PCI in Atrial Fibrillation. N Engl J Med 2019; 380 (16): 1509–24. DOI: 10.1056/NEJMoa1817083
21. Bahit MC, Lopes RD, Wojdyla DM et al. Apixaban in patients with atrial fibrillation and prior coronary artery disease: insights from the ARISTOTLE trial. Int J Cardiol 2013; 170 (2): 215–20. DOI: 10.1016/j.ijcard.2013.10.062
22. Lip GYH, Keshishian A, Li X et al. Effectiveness and Safety of Oral Anticoagulants Among Nonvalvular Atrial Fibrillation Patients. Stroke 2018; 49 (12): 2933–44. DOI: 10.1161/STROKEAHA.118.020232
23. Windecker S, Lopes RD, Massaro T et al. Antithrombotic Therapy in Patients With Atrial Fibrillation and Acute Coronary Syndrome Treated Medically or With Percutaneous Coronary Intervention or Undergoing Elective Percutaneous Coronary Intervention: Insights From the AUGUSTUS Trial. Circulation 2019; 140 (23): 1921–32. DOI: 10.1161/CIRCULATIONAHA.119.043308
24. Soliman EZ, Prineas RJ, Go AS et al. Chronic kidney disease and prevalent atrial fibrillation: the Chronic Renal Insufficiency Cohort (CRIC). Am Heart J 2010; 159 (6): 1102–7. DOI: 10.1016/j.ahj.2010.03.027
25. Marinigh R, Lane DA, Lip GY. Severe renal impairment and stroke prevention in atrial fibrillation: implications for thromboprophylaxis and bleeding risk. J Am Coll Cardiol 2011; 57 (12): 1339–48. DOI: 10.1016/j.jacc.2010.12.013
26. Olesen JB, Lip GY, Kamper AL et al. Stroke and bleeding in atrial fibrillation with chronic kidney disease. N Engl J Med 2012; 367 (7): 625–35. DOI:10.1056/NEJMoa1105594
27. Ocak G, Rookmaaker MB, Algra A et al. Chronic kidney disease and bleeding risk in patients at high cardiovascular risk: a cohort study. J Thromb Haemost 2018; 16 (1): 65–73. DOI: 10.1111/jth.13904
28. Böhm M, Ezekowitz MD, Connolly SJ et al. Changes in Renal Function in Patients With Atrial Fibrillation: An Analysis From the RE-LY Trial. J Am Coll Cardiol 2015; 65 (23): 2481–93. DOI: 10.1016/j.jacc.2015.03.577
29. Brodsky SV, Satoskar A, Chen J et al. Acute kidney injury during warfarin therapy associated with obstructive tubular red blood cell casts: a report of 9 cases. Am J Kidney Dis 2009; 54 (6): 1121–6. DOI: 10.1053/j.ajkd.2009.04.024
30. Brodsky SV, Nadasdy T, Rovin BH et al. Warfarin-related nephropathy occurs in patients with and without chronic kidney disease and is associated with an increased mortality rate. Kidney Int 2011; 80 (2): 181–9. DOI: 10.1038/ki.2011.44
31. Brodsky SV, Hebert LA. Anticoagulant-Related Nephropathy: Is an AKI Elephant Hiding in Plain View? J Am Coll Cardiol 2016; 68 (21): 2284–86. DOI: 10.1016/j.jacc.2016.09.926
32. Кропачева Е.С., Землянская О.А., Добровольский А.Б., Панченко Е.П. Клинические факторы и уровень антикоагуляции, определяющие развитие быстрой потери почечной функции у пациентов, длительно принимающих варфарин (5-летнее проспективное наблюдение). Атеротромбоз. 2018; 1: 107–21. DOI: 10.21518/2307-1109-2018-1-107-121
[Kropacheva E.S., Zemlyanskaya O.A., Dobrovolsky A.В., Panchenko Е.P. Clinical factors and anticoagulation level that determine the sudden loss of kidney function in patients long-taking warfarin (a 5-year prospective, observational study). Atherothrombosis. 2018; 1: 107–21. DOI: 10.21518/2307-1109-2018-1-107-121 (in Russian).]
33. Eikelboom JW, Connolly SJ, Gao P et al. Stroke risk and efficacy of apixaban in atrial fibrillation patients with moderate chronic kidney disease. J Stroke Cerebrovasc Dis 2012; 21 (6): 429–35. DOI: 10.1016/j.jstrokecerebrovasdis.2012.05.007
34. Hohnloser SH, Hijazi Z, Thomas L et al. Efficacy of apixaban when compared with warfarin in relation to renal function in patients with atrial fibrillation: insights from the ARISTOTLE trial. Eur Heart J 2012; 33 (22): 2821–30. DOI: 10.1093/eurheartj/ehs274
35. Pisters R, Lane DA, Nieuwlaat R et al. A novel user-friendly score (HAS-BLED) to assess 1-year risk of major bleeding in patients with atrial fibrillation: the Euro Heart Survey. Chest 2010; 138 (5): 1093–100. DOI: 10.1378/chest.10-0134
36. Lip GY, Frison L, Halperin JL, Lane DA. Comparative validation of a novel risk score for predicting bleeding risk in anticoagulated patients with atrial fibrillation: the HAS-BLED (Hypertension, Abnormal Renal/Liver Function, Stroke, Bleeding History or Predisposition, Labile INR, Elderly, Drugs/Alcohol Concomitantly) score. J Am Coll Cardiol 2011; 57 (2): 173–80. DOI: 10.1016/j.jacc.2010.09.024
37. An SJ, Kim TJ, Yoon BW. Epidemiology, Risk Factors, and Clinical Features of Intracerebral Hemorrhage: An Update. J Stroke 2017; 19 (1): 3–10. DOI: 10.5853/jos.2016.00864
38. Guo Y, Lip GY, Apostolakis S. Bleeding risk assessment and management in atrial fibrillation patients. Key messages for clinical practice from the European Heart Rhythm Association position statement. Pol Arch Med Wewn 2012; 122 (5): 235–42. DOI: 10.20452/pamw.1291
39. Barkun AN, Almadi M, Kuipers EJ et al. Management of Nonvariceal Upper Gastrointestinal Bleeding: Guideline Recommendations From the International Consensus Group. Ann Intern Med 2019; 171: 805–22. DOI: 10.7326/M19-1795
40. Roffi M, Patrono C, Collet JP et al. 2015 ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation: Task Force for the Management of Acute Coronary Syndromes in Patients Presenting without Persistent ST-Segment Elevation of the European Society of Cardiology (ESC). Eur Heart J 2016; 37 (3): 267–315. DOI: 10.1093/eurheartj/ehv320
41. Ibanez B, James S, Agewall S et al. 2017 ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation: The Task Force for the management of acute myocardial infarction in patients presenting with ST-segment elevation of the European Society of Cardiology (ESC). Eur Heart J 2018; 39 (2): 119–77. DOI: 10.1093/eurheartj/ehx393
42. Garcia D, Wruck L, De Caterina R et al. Abstract 16978: A History of GI Bleeding is Associated With Increased Risk of Subsequent Bleeding, but Not Stroke: Insights From the ARISTOTLE Trial. Circulation 2016; 134: A16978.
43. Garcia DA, Fisher DA, Mulder H et al. Gastrointestinal bleeding in patients with atrial fibrillation treated with Apixaban or warfarin: Insights from the Apixaban for Reduction in Stroke and Other Thromboembolic Events in Atrial Fibrillation (ARISTOTLE) trial. Am Heart J 2020; 221: 1–8. DOI: 10.1016/j.ahj.2019.10.013
44. Ray WA, Chung CP, Murray KT et al. Association of oral anticoagulants and proton pump inhibitor cotherapy with hospitalization for upper gastrointestinal tract bleeding. JAMA 2018; 320 (21): 2221–30. DOI: 10.1001/jama.2018.17242
45. Hornor MA, Duane TM, Ehlers AP et al. American College of Surgeons' Guidelines for the Perioperative Management of Antithrombotic Medication. J Am Coll Surg 2018; 227 (5): 521–36.e1. DOI: 10.1016/j.jamcollsurg.2018.08.183
46. Шляхто Е.В., Конради А.О., Арутюнов Г.П. и др. Руководство по диагностике и лечению болезней системы кровообращения в контексте пандемии COVID-19. Российский кардиологический журнал. 2020; 25 (3): 3801. DOI: 10.15829/1560-4071-2020-3-3801
[Shlyakho E.V., Konradi A.O., Arutyunov G.P. et al. Guidelines for the diagnosis and treatment of circulatory diseases in the context of the COVID-19 pandemic. Russian Journal of Cardiology. 2020; 25 (3): 3801. DOI: 10.15829/1560-4071-2020-3-3801 (in Russian).]
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30. Brodsky SV, Nadasdy T, Rovin BH et al. Warfarin-related nephropathy occurs in patients with and without chronic kidney disease and is associated with an increased mortality rate. Kidney Int 2011; 80 (2): 181–9. DOI: 10.1038/ki.2011.44
31. Brodsky SV, Hebert LA. Anticoagulant-Related Nephropathy: Is an AKI Elephant Hiding in Plain View? J Am Coll Cardiol 2016; 68 (21): 2284–86. DOI: 10.1016/j.jacc.2016.09.926
32. Kropacheva E.S., Zemlyanskaya O.A., Dobrovolsky A.В., Panchenko Е.P. Clinical factors and anticoagulation level that determine the sudden loss of kidney function in patients long-taking warfarin (a 5-year prospective, observational study). Atherothrombosis. 2018; 1: 107–21. DOI: 10.21518/2307-1109-2018-1-107-121 (in Russian).
33. Eikelboom JW, Connolly SJ, Gao P et al. Stroke risk and efficacy of apixaban in atrial fibrillation patients with moderate chronic kidney disease. J Stroke Cerebrovasc Dis 2012; 21 (6): 429–35. DOI: 10.1016/j.jstrokecerebrovasdis.2012.05.007
34. Hohnloser SH, Hijazi Z, Thomas L et al. Efficacy of apixaban when compared with warfarin in relation to renal function in patients with atrial fibrillation: insights from the ARISTOTLE trial. Eur Heart J 2012; 33 (22): 2821–30. DOI: 10.1093/eurheartj/ehs274
35. Pisters R, Lane DA, Nieuwlaat R et al. A novel user-friendly score (HAS-BLED) to assess 1-year risk of major bleeding in patients with atrial fibrillation: the Euro Heart Survey. Chest 2010; 138 (5): 1093–100. DOI: 10.1378/chest.10-0134
36. Lip GY, Frison L, Halperin JL, Lane DA. Comparative validation of a novel risk score for predicting bleeding risk in anticoagulated patients with atrial fibrillation: the HAS-BLED (Hypertension, Abnormal Renal/Liver Function, Stroke, Bleeding History or Predisposition, Labile INR, Elderly, Drugs/Alcohol Concomitantly) score. J Am Coll Cardiol 2011; 57 (2): 173–80. DOI: 10.1016/j.jacc.2010.09.024
37. An SJ, Kim TJ, Yoon BW. Epidemiology, Risk Factors, and Clinical Features of Intracerebral Hemorrhage: An Update. J Stroke 2017; 19 (1): 3–10. DOI: 10.5853/jos.2016.00864
38. Guo Y, Lip GY, Apostolakis S. Bleeding risk assessment and management in atrial fibrillation patients. Key messages for clinical practice from the European Heart Rhythm Association position statement. Pol Arch Med Wewn 2012; 122 (5): 235–42. DOI: 10.20452/pamw.1291
39. Barkun AN, Almadi M, Kuipers EJ et al. Management of Nonvariceal Upper Gastrointestinal Bleeding: Guideline Recommendations From the International Consensus Group. Ann Intern Med 2019; 171: 805–22. DOI: 10.7326/M19-1795
40. Roffi M, Patrono C, Collet JP et al. 2015 ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation: Task Force for the Management of Acute Coronary Syndromes in Patients Presenting without Persistent ST-Segment Elevation of the European Society of Cardiology (ESC). Eur Heart J 2016; 37 (3): 267–315. DOI: 10.1093/eurheartj/ehv320
41. Ibanez B, James S, Agewall S et al. 2017 ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation: The Task Force for the management of acute myocardial infarction in patients presenting with ST-segment elevation of the European Society of Cardiology (ESC). Eur Heart J 2018; 39 (2): 119–77. DOI: 10.1093/eurheartj/ehx393
42. Garcia D, Wruck L, De Caterina R et al. Abstract 16978: A History of GI Bleeding is Associated With Increased Risk of Subsequent Bleeding, but Not Stroke: Insights From the ARISTOTLE Trial. Circulation 2016; 134: A16978.
43. Garcia DA, Fisher DA, Mulder H et al. Gastrointestinal bleeding in patients with atrial fibrillation treated with Apixaban or warfarin: Insights from the Apixaban for Reduction in Stroke and Other Thromboembolic Events in Atrial Fibrillation (ARISTOTLE) trial. Am Heart J 2020; 221: 1–8. DOI: 10.1016/j.ahj.2019.10.013
44. Ray WA, Chung CP, Murray KT et al. Association of oral anticoagulants and proton pump inhibitor cotherapy with hospitalization for upper gastrointestinal tract bleeding. JAMA 2018; 320 (21): 2221–30. DOI: 10.1001/jama.2018.17242
45. Hornor MA, Duane TM, Ehlers AP et al. American College of Surgeons' Guidelines for the Perioperative Management of Antithrombotic Medication. J Am Coll Surg 2018; 227 (5): 521–36.e1. DOI: 10.1016/j.jamcollsurg.2018.08.183
46. Shlyakho E.V., Konradi A.O., Arutyunov G.P. et al. Guidelines for the diagnosis and treatment of circulatory diseases in the context of the COVID-19 pandemic. Russian Journal of Cardiology. 2020; 25 (3): 3801. DOI: 10.15829/1560-4071-2020-3-3801 (in Russian).
Авторы
А.И. Кочетков1, О.Д. Остроумова*1,2, Н.Л. Ляхова3, В.Н. Буторов1
1 ФГБОУ ДПО «Российская медицинская академия непрерывного профессионального образования» Минздрава России, Москва, Россия;
2 ФГАОУ ВО «Первый Московский государственный медицинский университет им. И.М. Сеченова» Минздрава России (Сеченовский Университет), Москва, Россия;
3 ГБУЗ «Городская клиническая больница им. С.П. Боткина» Департамента здравоохранения г. Москвы, Москва, Россия
*ostroumova.olga@mail.ru
1 ФГБОУ ДПО «Российская медицинская академия непрерывного профессионального образования» Минздрава России, Москва, Россия;
2 ФГАОУ ВО «Первый Московский государственный медицинский университет им. И.М. Сеченова» Минздрава России (Сеченовский Университет), Москва, Россия;
3 ГБУЗ «Городская клиническая больница им. С.П. Боткина» Департамента здравоохранения г. Москвы, Москва, Россия
*ostroumova.olga@mail.ru
________________________________________________
Aleksei I. Kochetkov1, Olga D. Ostroumova*1,2, Natalia L. Lyakhova3, Vasilii N. Butorov1
1 Russian Medical Academy of Continuous Professional Education, Moscow, Russia;
2 Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russia;
3 Botkin City Clinical Hospital, Moscow, Russia
*ostroumova.olga@mail.ru
Цель портала OmniDoctor – предоставление профессиональной информации врачам, провизорам и фармацевтам.