Aspirin, clopidogrel, and warfarin: Is the combination appropriate and effective or inappropriate and too dangerous?
Aspirin, clopidogrel, and warfarin: Is the combination appropriate and effective or inappropriate and too dangerous?
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DOI：
10.1345/aph.1k591
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发表时间：
2008-06-01
影响因子：
2.9
通讯作者：
Spinler, Sarah A.
中科院分区：
文献类型：
--
作者：
Hermosillo, A. Janelle;Spinler, Sarah A.
目的：回顾与阿司匹林、噻吩并吡啶和华法林联合使用相关的出血和临床结局的基本原理、临床实践指南建议和临床试验数据。使用MEDLINE进行英文文献检索（1966- 2008年3月）和检索词阿司匹林、氯吡格雷、噻氯匹定、噻吩并吡啶、华法林、抗血小板、抗凝剂、心肌梗死、房颤，和经皮冠状动脉介入治疗（PCI）。其他参考文献通过回顾检索到的文章的参考文献引文来确定。研究选择和数据提取：适用的数据是从已发表的报告和研究中提取的，包括临床结局或不良事件。数据综合：临床指南建议抗血小板和抗凝剂的组合主要是基于编写委员会的共识。到目前为止，只有一项随机临床试验评价了华法林与双联抗血小板治疗（即三联抗血栓治疗）的安全性和有效性。其他已发表的数据来自病例系列、观察性研究和病例对照研究，主要涉及接受PCI和冠状动脉内支架置入术的患者。12项研究中有4项报告大出血事件的风险未增加。在其他8项研究中，三联抗血栓治疗报告出血事件增加3- 6倍。仅6项研究报告了缺血事件。只有2项研究观察到一个额外的好处，在减少缺血事件，1项研究报告恶化的缺血性结局与三联抗血栓治疗方案相比，双重antithrombotic therapy.CONCLUSIONS：有关阿司匹林，噻吩并吡啶和华法林的伴随用药的可用指南是基于有限的试验数据和共识判断。总体而言，血管疾病患者的三联抗血栓治疗选择被认为是个体患者的临床判断问题，基于处方者对患者复发性缺血事件风险、预期治疗持续时间和患者出血风险之间的感知平衡。
OBJECTIVE: To review the rationale, clinical practice guideline recommendations, and clinical trial data describing bleeding and clinical outcomes associated with the use of the combination of aspirin, a thienopyridine, and warfarin.DATA SOURCES: An English-language literature search was conducted using MEDLINE (1966-March 2008) and the search terms aspirin, clopidogrel, ticlopidine, thienopyridine, warfarin, antiplatelet, anticoagulant, myocardial infarction, atrial fibrillation, and percutaneous coronary intervention (PCI). Additional references were identified by reviewing reference citations of articles retrieved.STUDY SELECTION AND DATA EXTRACTION: Applicable data were extracted from published reports and studies that included either clinical outcomes or adverse events.DATA SYNTHESIS: Clinical guidelines recommend the combination of antiplatelets and anticoagulants based largely on writing committee consensus. To date, only one randomized clinical trial has evaluated the safety and efficacy of adding warfarin to dual antiplatelet therapy (ie, triple antithrombotic therapy). Other published data are from case series, observational studies, and case-controlled studies primarily of patients undergoing PCI with intracoronary stent placement. Four of 12 studies reported no increased risk of major bleeding events. In the other 8 studies, a 3- to 6-fold increase in bleeding events was reported with triple antithrombotic therapy. Ischemic events were reported in only 6 of the studies. Only 2 studies observed an additional benefit in the reduction of ischemic events, and 1 study reported worsened ischemic outcomes with the triple antithrombotic regimen compared with dual antithrombotic therapy.CONCLUSIONS: Available guidelines pertaining to the concomitant administration of aspirin, a thienopyridine, and warfarin are based on limited trial data and consensus judgment. Overall, selection of triple antithrombotic therapy for patients with vascular disease is considered a matter of clinical judgment for an individual patient based on the prescriber's perceived balance between the patient's risk for recurrent ischemic events, expected duration of treatment, and patient's risk for bleeding.