Kongres ESC Amsterdam 2013 – podwójna terapia przeciwpłytkowa w świetle wyników z rejestru PARIS

Październik 31, 2013  |  Udostępnij  | 
Angioplastyka naczyń wieńcowych

Angioplastyka naczyń wieńcowych

Kolejny już artykuł poświęcimy wynikom badań prezentowanych podczas wrześniowego kongresu Europejskiego Towarzystwa Kardiologicznego (ESC). Tym razem przyjrzymy się danym pochodzącym z rejestru PARIS [1]. To wieloośrodkowe, prospektywne, obserwacyjne badanie miało na celu stwierdzenie, jakie konsekwencje dla ryzyka sercowo-naczyniowego przynosi odstawienie aspiryny i klopidogrelu u chorych po angioplastyce naczyń wieńcowych z implantacją stentu. Zapraszamy do lektury!

Do rejestru PARIS włączono łącznie ponad 5000 chorych z 15 ośrodków europejskich i amerykańskich, po skutecznej implantacji stentu do jednej z tętnic wieńcowych, którzy zgodnie z przyjętymi standardami byli wypisywani z zaleceniem przyjmowania podwójnej terapii przeciwpłytkowej. Osoby badane w momencie przerwania leczenia kwasem acetylosalicylowym (ASA) i klopidogrelem przydzielano do 3 grup w zależności od przyczyn, z jakich zaprzestali przyjmowania leków. Pierwszą stanowili chorzy, których terapia dobiegła końca zgodnie z zaleceniami lekarza, drugą – pacjenci, którzy musieli czasowo odstawić leki przeciwpłytkowe ze względu na czekający ich zabieg operacyjny, a trzecią – chorzy, którzy przerwali leczenie ignorując zalecenia lekarskie lub z powodu powikłań krwotocznych. Czas, na jaki przerywano terapie, był określony jako krótki (gdy nie przekraczał 5 dni), tymczasowy (między 6 a 30 dni) lub stały (gdy przekraczał miesiąc). Podczas dwuletniego okresu obserwacji odnotowywano następujące pierwszorzędowe punkty końcowe: zgon z przyczyn sercowo-naczyniowych, zawał serca, konieczność ponownej rewaskularyzacji oraz zakrzepicę w stencie. Analizując zgromadzone dane zaobserwowano, że spośród pacjentów zaprzestających przyjmowania leków zgodnie z zaleceniami lekarskimi zdecydowana większość (87%) odstawiała jedynie klopidogrel, a jedynie nieliczni oba leki przeciwpłytkowe. Zupełnie inaczej wyglądała sytuacja w pozostałych grupach.  Aż 70% osób tymczasowo przerywających leczenie przeciwpłytkowe z powodu czekającej ich operacji oraz 50% chorych nieprzestrzegających zaleceń lekarza zaprzestawało jednocześnie przyjmowania zarówno  ASA jak i klopidogrelu. Łącznie pierwszorzędowy punkt końcowy wystąpił u 11,5% obserwowanych pacjentów, z których aż 74% przyjmowało leki zgodnie z zaleceniami. Jednak, po porównaniu ryzyka względnego w poszczególnych grupach chorych okazało się, że było ono zwiększone odpowiednio do poziomu 1,41 (p=0,1) u osób tymczasowo nie leczonych oraz do poziomu 1,5 (p<0,005) u pacjentów nie przestrzegających zaleceń i tych, które odstawiły leki z powodu krwawienia. Dla kontrastu chorzy, których sytuacja kliniczna według lekarza prowadzącego była na tyle dobra, że mogli bezpiecznie odstawić klopidogrel (a czasem także ASA), osiągnęli poziom ryzyka względnego niższy od średniej dla osób przyjmujących regularnie oba leki przeciwpłytkowe (HR=0,63). Największe ryzyko zdarzeń sercowo-naczyniowych obserwowano w pierwszych 7 dniach od przerwania terapii (HR=7,04), podczas gdy między 8 a 30 dniem wynosiło ono już tylko 2,17, a po miesiącu 1,3. Rezultat nie zależał od rodzaju wszczepionego stentu.

Wyniki rejestru PARIS pokazują, że przedwczesne przerwanie leczenia przeciwpłytkowego po zabiegu przezskórnej angioplastyki wieńcowej, niezależnie od przyczyny, wiąże się ze zwiększonym ryzykiem zdarzeń sercowo-naczyniowych. Jednocześnie badanie to dowodzi, że nie ma korzyści z przedłużonego przyjmowania klopidogrelu (a w niektórych przypadkach także ASA) w grupie pacjentów, którzy kwalifikują się do przerwania terapii, co stoi w sprzeczności z przekonaniem wielu lekarzy.

1. Mehran R et al., Cessation of dual antiplatelet treatment and cardiac events after percutaneous coronary intervention (PARIS): 2 year results from a prospective observational study. Lancet. 2013 Aug 30 [Epub ahead of print]



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