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    臨床上可見多重抗栓藥物引起的出血，包括心肌梗死冠脈介入術(shù)（PCI）后合并房顫使用三聯(lián)藥物抗栓療法的患者。

    多重抗栓藥物療法對于心肌梗死冠脈介入術(shù)（PCI）后合并房顫的患者的治療效果仍有很多不確定性。研究者調(diào)查了發(fā)生心肌梗死后施行經(jīng)皮下冠脈介入術(shù)（PCI）后出現(xiàn)房顫的患者使用多重抗栓藥物療法后發(fā)生出血的風(fēng)險及時間窗。

    研究納入了丹麥2000年至2009年發(fā)生過心肌梗死并確診房顫合并心梗的11480名患者，這些患者同時施行過冠脈介入術(shù)（PCI），在住院治療期間經(jīng)過抗栓治療后出現(xiàn)過致命或輕微的出血。所用多重抗栓藥物療法包括：抗栓三聯(lián)療法維生素K拮抗劑+阿司匹林+氯吡格雷；維生素K拮抗劑+抗血小板藥和阿司匹林+氯吡格雷雙聯(lián)抗血小板藥物。研究者通過Cox回歸模型評估了出血事件發(fā)生率，并調(diào)整了危險比。結(jié)果發(fā)現(xiàn)，1年內(nèi)有728名（6.3%）患者發(fā)生出血，79名（0.7%）是致命性的。治療30天內(nèi)，上述三種抗栓療法在每100名病人中的出血發(fā)生率分別為22.6%，20.3%，14.3%。治療早期（90天內(nèi)）和治療后期（90-360天內(nèi)）采用三聯(lián)抗栓療法的出血率高于維生素K拮抗劑+抗血小板藥的療法，危險比分別為1.47和1.36。

    高風(fēng)險出血是心肌梗死/冠脈介入術(shù)（PCI）后發(fā)生房顫患者采用三聯(lián)抗栓療法后出現(xiàn)的急性事件，三聯(lián)抗栓療法持續(xù)增高的出血風(fēng)險提示該療法不具安全窗，因此只有經(jīng)過安全評估的心肌梗死患者才可使用三聯(lián)抗栓療法。

    Abstract

    Background—Uncertainty remains over optimal antithrombotic treatment of patients with atrial fibrillation presenting with myocardial infarction and/or undergoing percutaneous coronary intervention. We investigated the risk and time frame for bleeding following myocardial infarction/percutaneous coronary intervention in patients with atrial fibrillation according to antithrombotic treatment.

    Methods and Results—Patients with atrial fibrillation and admitted with myocardial infarction or for percutaneous coronary intervention between 2000 and 2009 (11 480 subjects, mean age 75.6 years [SD ±10.3], males 60.9%) were identified by individual level linkage of nationwide registries in Denmark. Fatal or nonfatal (requiring hospitalization) bleeding was determined according to antithrombotic treatment regimen: t**le therapy (TT) with vitamin K antagonist (VKA)+aspirin+clopidogrel, VKA+antiplatelet, and dual antiplatelet therapy with aspirin+clopidogrel. We calculated crude incidence rates and adjusted hazard ratios by Cox regression models. Within 1 year, 728 bleeding events were recorded (6.3%); 79 were fatal (0.7%). Within 30 days, rates were 22.6, 20.3, and 14.3 bleeding events per 100 person-years for TT, VKA+antiplatelet, and dual antiplatelet therapy, respectively. Both early (within 90 days) and delayed (90–360 days) bleeding risk with TT exposure in relation to VKA+antiplatelet was increased; hazard ratio 1.47 (1.04;2.08) and 1.36 (0.95;1.95), respectively. No significant difference in thromboembolic risk was observed for TT versus VKA+antiplatelet; hazard ratio, 1.15 (0.95;1.40).

    Conclusions—High risk of bleeding is immediately evident with TT after myocardial infarction/percutaneous coronary intervention in patients with atrial fibrillation. A continually elevated risk associated with TT indicates no safe therapeutic window, and TT should only be prescribed after thorough bleeding risk assessment of patients.