Antitrombotska terapija u koronarnih bolesnika s visokim ishemijskim rizikom

master's thesis

• Title (english): Antithrombotic therapy in coronary patients with high ischemic risk
• Author: Martin Novosel
• Mentor: Matias Trbušić (mentor)
• Committee member: Nikola Bulj (predsjednik povjerenstva)
• Committee member: Boško Skorić (član povjerenstva)
• Committee member: Matias Trbušić (član povjerenstva)
• Granter: University of Zagreb; School of Medicine; (Department of Internal Medicine); Zagreb
• Defense date and country: 2021-07-16, Croatia
• Scientific / art field, discipline and subdiscipline: BIOMEDICINE AND HEALTHCARE; Clinical Medical Sciences; Internal Medicine

Abstract

Strategije antitrombotske terapije u koronarnih bolesnika s visokim ishemijskim rizikom opisane su u brojnim znanstvenim radovima i smjernicama raznih kardioloških društva. Cilj ovog preglednog rada je sveobuhvatni pregled relevantne literature i smjernica antitrombotskog liječenja koronarnih bolesnika u različitim okolnostima koronarne bolesti. Antitrombotska terapija sastoji se od antiagregacijskih i antikoagulantnih lijekova i čini temelj farmakološkog liječenja koronarnih bolesnika. Adekvatna primjena antitrombotske terapije obuhvaća ocjenjivanje rizika ishemije nasuprot riziku krvarenja za svakog pojedinog bolesnika, a bolesnici stratificirani u skupinu visokog ishemijskog rizika zahtijevaju posebnu strategiju primjene antitrombotske terapije. U procjeni rizika ishemije i krvarenja nakon PCI koriste se PRECISE-DAPT i DAPT bodovni sustavi te ESC smjernice za NSTEMI iz 2020. godine. Strategije antitrombotske terapije raspravljene su prije i nakon zahvata revaskularizacije. Prije perkutane koronarne intervencije u STEMI bolesnika indicirana je acetilsalicilna kiselina u kombinaciji s visokopotentnim P2Y12 inhibitorom (tikagrelor ili prasugrel), a neposredno prije dodaje se antikoagulans (nefrakcionirani heparin). Kod NSTEMI prednost primjene ima prasugrel s acetilsalicilnom kiselinom uz nefrakcionirani heparin neposredno prije zahvata. Kod bolesnika sa stabilnom koronarnom bolešću klopidogrel uz acetilsalicilnu kiselinu je lijek izbora (tikagrelor ili prasugrel su razmotreni kod složenog zahvata revaskularizacije). Nakon PCI u sklopu akutnog koronarnog sindroma, standardna je antitrombotska terapija u trajanju od 12 mjeseci, a kod pacijenata visokog ishemijskog rizika razmatra se produženje terapije (klopidogrel, prasugrel ili tikagrelor u reduciranoj dozi). Nadalje, novitet u izboru antitrombotske terapije nakon PCI je reducirana doza rivaroksabana. U kroničnom koronarnom sindromu nakon PCI indicirana je antitrombotska terapija u trajanju od 6 mjeseci. Prije CABG operacije potrebna je deeskalacija antitrombotske terapije, a nastavak nakon 48 do 96 sati postoperativno. Adekvatna primjena antitrombotske terapije zahtijeva strogo individualiziran pristup. Opis smjernica i tablični prikaz preuzet je iz najnovijih smjernica Europskog kardiološkog društva, te uspoređen sa smjernicama kardioloških društava Sjedinjenih Američkih Država, Kanade i Japana.

Abstract (english)

There are numerous different guidelines and papers that are written and applied to the antithrombotic treatment of coronary patients with high ischemic risk. This presents a great challenge for a cardiologist to find the optimal antithrombotic therapy and weigh the bleeding risk to antithrombotic benefit ratio in every patient. The paper aims to comprehensively review the existing strategies of antithrombotic treatment in different types of coronary patients. Antithrombotic therapy includes antiplatelet and anticoagulant agents, which are a basis of pharmacological therapy in patients with coronary artery disease. Coronary patients with high ischemic risk require a particular strategy for the application of antithrombotic therapy. The PRECISE-DAPT and DAPT scoring systems and the 2020 ESC guidelines for NSTEMI are used to assess the risk of ischemia and bleeding after PCI. Antithrombotic therapy strategies were discussed before and after the revascularization procedure. Prior to percutaneous coronary intervention in patients with STEMI, acetylsalicylic acid is indicated in combination with a highly potent P2Y12 inhibitor (ticagrelor or prasugrel), and an anticoagulant (unfractionated heparin) is given immediately before. In NSTEMI, prasugrel with acetylsalicylic acid and unfractionated heparin immediately before the procedure are preferred. In patients with stable coronary artery disease, clopidogrel with acetylsalicylic acid is the drug of choice (ticagrelor or prasugrel are considered in a complex revascularization procedure). Following PCI as part of an acute coronary syndrome, antithrombotic therapy for 12 months is the standard treatment, and prolonged therapy (clopidogrel, prasugrel, or ticagrelor in a reduced dose) is considered in patients with high ischemic risk. Furthermore, a novelty in the choice of antithrombotic therapy after PCI is the reduced dose of rivaroxaban. In chronic coronary syndrome after PCI, antithrombotic therapy for six months is indicated. Deescalation of antithrombotic therapy is required before CABG surgery and continuation after 48 to 96 hours postoperatively. Adequate application of antithrombotic therapy requires a strictly individualized approach. Guidelines reviewed in these papers are the European Society of Cardiology, American College of Cardiology, Japan Circulation Society, and Canadian Cardiovascular Society.

• Keywords: antitrombotska terapija; koronarni bolesnici s visokim ishemijskim rizikom; perkutana koronarna intervencija; aortokoronarno premoštenje
• Keywords (english): antithrombotic treatment; percutaneous coronary intervention; coronary artery bypass surgery; coronary patients with high ischemic risk
• Language: croatian
• URN:NBN: urn:nbn:hr:105:103543
• Study programme: Title: Medicine; Study programme type: university; Study level: integrated undergraduate and graduate; Academic / professional title: doktor/doktorica medicine (doktor/doktorica medicine)
• Type of resource: Text
• File origin: Born digital
• Access conditions: Open access
• Created on: 2022-03-24 11:01:13