Осложнения двойной антитромбоцитарной терапии со стороны желудочно-кишечного тракта у пациентов с ишемической болезнью сердца: стратификация риска, современная тактика ведения

Деева Е.С., Исайкина М.А., Трушина О.Ю., Фомин В.В., Погонин А.В., Тамкаева М.К. Осложнения двойной антитромбоцитарной терапии со стороны желудочно-кишечного тракта у пациентов с ишемической болезнью сердца: стратификация риска, современная тактика ведения. Терапевтический архив. 2026;98(2):125–130. DOI: 10.26442/00403660.2026.02.203532

© ООО «КОНСИЛИУМ МЕДИКУМ», 2026 г.

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Deeva ES, Isaikina MA, Trushina OIu, Fomin VV, Pogonin AV, Tamkaeva MK. Gastrointestinal complications of dual antiplatelet therapy in patients with ischemic heart disease: risk stratification, current management tactics. A review. Terapevticheskii Arkhiv (Ter. Arkh.). 2026;98(2):125–130. DOI: 10.26442/00403660.2026.02.203532

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Аннотация

Ишемическая болезнь сердца является одной из основных причин смерти во всем мире, а антиагрегантная терапия имеет решающее значение как для ее профилактики, так и лечения. В обзорной статье приведены данные клинических исследований, позволяющие определить тактику ведения пациентов с высоким риском возникновения осложнений со стороны желудочно-кишечного тракта (ЖКТ) на фоне приема двойной антиагрегантной терапии. Описаны основные факторы риска возникновения осложнений, такие как доза ацетилсалициловой кислоты, язва или кровотечение из верхних отделов ЖКТ в анамнезе, пожилой возраст, одновременное применение антикоагулянтов, нестероидных противовоспалительных препаратов, не содержащих ацетилсалициловую кислоту, включая нестероидные противовоспалительные препараты, избирательно блокирующие циклооксигеназу-2, инфекция Helicobacter pylori. Рассмотрены механизм действия антиагрегантных препаратов и патогенез их повреждающего действия на слизистую оболочку ЖКТ, применение гастропротективной терапии с целью профилактики и лечения уже имеющегося повреждения слизистой оболочки ЖКТ.

Ключевые слова: ишемическая болезнь сердца, острый коронарный синдром, желудочно-кишечное кровотечение, язвенная болезнь желудка, язвенная болезнь двенадцатиперстной кишки, Helicobacter pylori, факторы риска, прогноз, терапия

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Coronary heart disease is one of the leading causes of death worldwide, and antiaggregant therapy is crucial for both its prevention and treatment. The review article presents the data of clinical trials that allow to determine the tactics of management of patients at high risk of gastrointestinal complications on the background of dual antiaggregant therapy. The main risk factors for complications are described, such as: acetylsalicylic acid dose, ulcer or bleeding from the upper GI tract in anamnesis, advanced age, concomitant use of anticoagulants, non-aspirin non-steroidal anti-inflammatory drugs, including COX-2-selective non-steroidal anti-inflammatory drugs, Helicobacter pylori infection. The mechanism of action of antiaggregant drugs and pathogenesis of their damaging effect on the GI mucosa, the use of gastroprotective therapy for the prevention and treatment of existing damage to the GI mucosa are considered.

Keywords: ischemic heart disease, acute coronary syndrome, gastrointestinal bleeding, gastric ulcer, duodenal ulcer, Helicobacter pylori, risk factors, prognosis, therapy

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1. Barbarash OL, Karpov YA, Panov AV, et al. 2024 Clinical practice guidelines for Stable coronary artery disease. Russian Journal of Cardiology. 2024;29(9):6110 (in Russian). DOI:10.15829/1560-4071-2024-6110
2. Marlicz W, Loniewski I, Koulaouzidis G. Proton Pump Inhibitors, Dual Antiplatelet Therapy, and the Risk of Gastrointestinal Bleeding. Mayo Clin Proc. 2022;97(4):648-51. DOI:10.1016/j.mayocp.2022.02.023
3. Shakhmatova OO, Komarov AL, Korobkova VV, et al. Upper gastrointestinal bleeding in patients with stable coronary artery disease (registry of antithrombotic therapy “REGATТA” results). Terapevticheskii Arkhiv (Ter. Arkh.). 2020;92(9):30-8 (in Russian). DOI:10.26442/00403660.2020.09.000699
4. Chazova IE, Solntseva TD, Sivakova OA, et al. Russian Medical Society for Arterial Hypertension expert consensus. Arterial hypertension and adherence to antihypertensive therapy. Systemic Hypertension. 2024;21(2):7-17 (in Russian). DOI:10.38109/2075-082x-2024-2-5-15
5. Rubinfeld GD, Berger JS, Smilowitz NR. Acute Myocardial Infarction Following Hospitalization for Gastrointestinal Bleeding: Incidence, Predictors, Management, and Outcomes. Am J Med. 2022;135(8):e263-78. DOI:10.1016/j.amjmed.2022.03.030
6. Su X, Li J, Du L, et al. Acute myocardial infarction post-gastrointestinal bleeding: A clinical dilemma with poor prognosis. Saudi J Gastroenterol. 2023;29(1):47-52. DOI:10.4103/sjg.sjg_301_22
7. Kropacheva ES, Zemlyanskaya OA, Krivosheeva EN, Panchenko EP. Resumption of anticoagulant therapy after major bleeding and the risk of negative events in patients with atrial fibrillation (based on REGistry of Long-term AnTithrombotic TherApy-2 – REGATA). Terapevticheskii Arkhiv (Ter. Arkh.). 2023;94(12):1374-80 (in Russian). DOI:10.26442/00403660.2022.12.201994
8. Visseren FLJ, Mach F, Smulders YM, et al. 2021 ESC Guidelines on cardiovascular disease prevention in clinical practice. Eur Heart J. 2021;42(34):3227-337. DOI:10.1093/eurheartj/ehab484
9. Capodanno D, Angiolillo DJ. Personalised antiplatelet therapies for coronary artery disease: what the future holds. Eur Heart J. 2023;44(32):3059-72. DOI:10.1093/eurheartj/ehad362
10. Malfertheiner P, Megraud F, Rokkas T, et al. Management of Helicobacter pylori infection: the Maastricht VI/Florence consensus report. Gut. 2022;gutjnl-2022-327745. DOI:10.1136/gutjnl-2022-327745
11. Huard K, Haddad K, Saada Y, et al. Prevalence of H. pylori among patients undergoing coronary angiography (The HP-DAPT prevalence study). Sci Rep. 2022;12(1):16591. DOI:10.1038/s41598-022-17034-0
12. Komarov AL, Shahmatova OO, Korobkova VV, et al. Gastric mucosa condition in patients with coronary artery disease and high risk of gastrointestinal bleeding (register REGATTA-1). Terapevticheskii Arkhiv (Ter. Arkh.). 2022;93(12):1457-62 (in Russian). DOI:10.26442/00403660.2021.12.201224
13. Wärme J, Sundqvist M, Mars K, et al. Helicobacter pylori screening in clinical routine during hospitalization for acute myocardial infarction. Am Heart J. 2021;231:105-9. DOI:10.1016/j.ahj.2020.10.072
14. Hawkey C, Avery A, Coupland CAC, et al. Helicobacter pylori eradication for primary prevention of peptic ulcer bleeding in older patients prescribed aspirin in primary care (HEAT): a randomized, double-blind, placebo-controlled trial. Lancet. 2022;400(10363):1597-606. DOI:10.1016/S0140-6736(22)01843-8
15. Wärme J, Sundqvist MO, James S, Hofmann R. Screening for Helicobacter pylori infection in patients with cardiovascular and gastrointestinal disease. Nat Rev Cardiol. 2024;21(8):593. DOI:10.1038/s41569-024-01028-8
16. Angiolillo DJ, Galli M, Collet JP, et al. Antiplatelet therapy after percutaneous coronary intervention. EuroIntervention. 2022;17(17):e1371-96. DOI:10.4244/EIJ-D-21-00904
17. Collet JP, Thiele H, Barbato E, et al. 2020 ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation. Eur Heart J. 2021;42(14):1289-367. DOI:10.1093/eurheartj/ehaa575
18. Patrono C. Low-dose aspirin for the prevention of atherosclerotic cardiovascular disease. Eur Heart J. 2024;45(27):2362-76. DOI:10.1093/eurheartj/ehae324
19. Yeomans ND, Lanas AI, Talley NJ, et al. Prevalence and incidence of gastroduodenal ulcers during treatment with vascular protective doses of aspirin. Aliment Pharmacol Ther. 2005;22(9):795-801. DOI:10.1111/j.1365-2036.2005.02649.x
20. Capodanno D, Baber U, Bhatt DL, et al. P2Y(12) inhibitor monotherapy in patients undergoing percutaneous coronary intervention. Nat Rev Cardiol. 2022;19(12):829-44. DOI:10.1038/s41569-022-00725-6
21. Abrignani MG, Gatta L, Gabrielli D, et al. Gastroprotection in patients on antiplatelet and/or anticoagulant therapy: a position paper of National Association of Hospital Cardiologists (ANMCO) and the Italian Association of Hospital Gastroenterologists and Endoscopists (AIGO). Eur J Intern Med. 2021;85:1-13. DOI:10.1016/j.ejim.2020.11.014
22. Alaamri S, Dalbhi SA. Risk of bleeding with ticagrelor in elderly patients over 75 years old: A systematic review and meta-analysis. Medicine (Baltimore). 2021;100(44):e27398. DOI:10.1097/MD.0000000000027398
23. Magnani G, Ardissino D, Im K, et al. Predictors, Type, and Impact of Bleeding on the Net Clinical Benefit of Long-Term Ticagrelor in Stable Patients With Prior Myocardial Infarction. J Am Heart Assoc. 2021;10(4):e017008. DOI:10.1161/JAHA.120.017008
24. Guo CG, Chen L, Chan EW, et al. Systematic review with meta-analysis: the risk of gastrointestinal bleeding in patients taking third-generation P2Y12 inhibitors compared with clopidogrel. Aliment Pharmacol Ther. 2019;49(1):7-19. DOI:10.1111/apt.15059
25. Ide Y, Morikawa G, Yoshida K, et al. The risk of upper gastrointestinal bleeding associated with concomitant proton pump inhibitor administration during dual antiplatelet therapy with aspirin and prasugrel: a retrospective single-center study. J Pharm Health Care Sci. 2024;10(1):76. DOI:10.1186/s40780-024-00398-y
26. Han Y, Liao Z, Li Y, et al. Magnetically Controlled Capsule Endoscopy for Assessment of Antiplatelet Therapy-Induced Gastrointestinal Injury. J Am Coll Cardiol. 2022;79(2):116-28. DOI:10.1016/j.jacc.2021.10.028
27. Chichareon P, Chamnarnphol N, Chandavimol M, et al. Updated CRUSADE score to predict in-hospital bleeding: External validation in the Thai percutaneous coronary intervention registry. Catheter Cardiovasc Interv. 2024;103(2):268-75. DOI:10.1002/ccd.30940
28. Lv M, Zheng X, Wu T, et al. A New Score for Predicting Acute Gastrointestinal Bleeding in Patients Administered Oral Antiplatelet Drugs. Front Pharmacol. 2020;11:571605. DOI:10.3389/fphar.2020.571605
29. Brazhnik VA, Minushkina LO, Averkova AO, et al. Bleeding risk scales in patients with acute coronary syndrome: place of the ORACUL scale. Cardiovascular Therapy and Prevention. 2020;19(5):2333 (in Russian). DOI:10.15829/1728-8800-2020-2333
30. Brazhnik VA, Minushkina LO, Erlikh AD, et al. Using the ORACLE Risk Score to Assess Hemorrhagic Risk in Patients with Acute Coronary Syndrome and Atrial Fibrillation. Rational Pharmacotherapy in Cardiology. 2021;17(1):11-5 (in Russian). DOI:10.20996/1819-6446-2021-01-01
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Авторы

Е.С. Деева*^1,2, М.А. Исайкина¹, О.Ю. Трушина¹, В.В. Фомин¹, А.В. Погонин², М.К. Тамкаева²

¹ФГАОУ ВО «Первый Московский государственный медицинский университет им. И.М. Сеченова» Минздрава России (Сеченовский Университет), Москва, Россия;
²ГБУЗ «Городская клиническая больница им. М.П. Кончаловского Департамента здравоохранения г. Москвы», Зеленоград, Россия
*katydeeva@yandex.ru

________________________________________________

Ekaterina S. Deeva*^1,2, Maria A. Isaikina¹, Olga Iu. Trushina¹, Viсtor V. Fomin¹, Alexey V. Pogonin²,
Makka K. Tamkaeva²

¹Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russia;
²Konchalovsky City Clinical Hospital of Moscow City Health Department (Konchalovsky Clinic), Zelenograd, Russia
*katydeeva@yandex.ru

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