medicina56巻2号

2019年02月発行

特集 抗血栓療法のジレンマ—予防すべきは血栓か，出血か？ 高い出血リスクに対する対策

抗血小板療法中の出血高リスクとその対策

著者： 横井宏佳¹

所属機関： ¹福岡山王病院循環器センター

ページ範囲：P.294 - P.300

Point
◎長期にわたる抗血小板薬の2剤併用療法（DAPT）には出血性合併症のリスクがあり，世界的にDAPT期間短縮の流れにある．
◎日本人における高出血リスク（HBR）患者の多くは高血栓リスク患者でもあることから，欧米のガイドライン通りにDAPT期間を短縮することの有効性・安全性は明らかではない．
◎DAPT患者に多い出血性合併症として，消化管出血および頭蓋内出血が挙げられる．
◎出血時の対応は血行動態の安定化と止血，抗血小板薬の休薬となるが，大量出血の場合は血小板輸血を考慮する．

参考文献

1）Neumann FJ, et al：2018 ESC/EACTS Guidelines on myocardial revascularization. Eur Heart J 40：87-165, 2019

2）Nikolsky E, et al：Gastrointestinal bleeding in patients with acute coronary syndromes；Incidence, predictors, and clinical implications；Analysis from the ACUITY（Acute Catheterization and Urgent Intervention Triage Strategy） trial. J Am Coll Cardiol 54：1293-1302, 2009

3）Généreux P, et al：Incidence, predictors, and impact of post-discharge bleeding after percutaneous coronary intervention. J Am Coll Cardiol 66：1036-1045, 2015

4）Kazi DS, et al：Association of spontaneous bleeding and myocardial infarction with long-term mortality after percutaneous coronary intervention. J Am Coll Cardiol 65：1411-1420, 2015

5）Levine GN, et al：2011 ACCF/AHA/SCAI guideline for percutaneous coronary intervention；A report of the American College of Cardiology Foundation/American Heart Association task force on practice guidelines and the Society for Cardiovascular Angiography and Interventions. Circulation 124：e574-651, 2011

6）Virmani R, et al：Localized hypersensitivity and late coronary thrombosis secondary to a sirolimus-eluting stent：should we be cautious？ Circulation 109：701-705, 2004

7）Levine GN, et al：2016 ACC/AHA guideline focused update on duration of dual antiplatelet therapy in patients with coronary artery disease；A report of the American College of Cardiology/American Heart Association task force on clinical practice guidelines；An update of the 2011 ACCF/AHA/SCAI guideline for percutaneous coronary intervention, 2011 ACCF/AHA guideline for coronary artery bypass graft surgery, 2012 ACC/AHA/ACP/AATS/PCNA/SCAI/STS guideline for the diagnosis and management of patients with stable ischemic heart disease, 2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction, 2014 AHA/ACC guideline for the management of patients with non-ST-elevation acute coronary syndromes, and 2014 ACC/AHA guideline on perioperative cardiovascular evaluation and management of patients undergoing noncardiac surgery. Circulation 134：e123-155, 2016

8）Natsuaki M, et al：Prediction of thrombotic and bleeding events after percutaneous coronary intervention；CREDO-Kyoto thrombotic and bleeding risk scores. J Am Heart Assoc 7：e008708, 2018

9）Varenne O, et al：Drug-eluting stents in elderly patients with coronary artery disease（SENIOR）；A randomised single-blind trial. Lancet 391：41-50, 2018

10）Mauri L, et al：Twelve or 30 months of dual antiplatelet therapy after drug-eluting stents. N Engl J Med 371：2155-2166, 2014

11）Bhatt DL, et al：Clopidogrel with or without omeprazole in coronary artery disease. N Engl J Med 363：1909-1917, 2010

12）Gibson CM, et al：Prevention of bleeding in patients with atrial fibrillation undergoing PCI. N Engl J Med 375：2423-2434, 2016

13）Cannon CP, et al：Dual antithrombotic therapy with dabigatran after PCI in atrial fibrillation. N Engl J Med 377：1513-1524, 2017

14）Dewilde WJ, et al：Use of clopidogrel with or without aspirin in patients taking oral anticoagulant therapy and undergoing percutaneous coronary intervention；An open-label, randomised, controlled trial. Lancet 381：1107-1115, 2013

15）Fiedler KA, et al：Duration of triple therapy in patients requiring oral anticoagulation after drug-eluting stent implantation；The ISAR-TRIPLE trial. J Am Coll Cardiol 65：1619-1629, 2015

16）Angiolillo DJ, et al：Antithrombotic therapy in patients with atrial fibrillation treated with oral anticoagulation undergoing percutaneous coronary intervention；A North American perspective-2018 update. Circulation 138：527-536, 2018

17）Diener HC, et al：Aspirin and clopidogrel compared with clopidogrel alone after recent ischaemic stroke or transient ischaemic attack in high-risk patients（MATCH）；Rrandomised, double-blind, placebo-controlled trial. Lancet 364：331-337, 2004

18）Yamamoto K, et al：Impact of CYP2C19 polymorphism on residual platelet reactivity in patients with coronary heart disease during antiplatelet therapy. J Cardiol 57：194-201, 2011

19）Wiviott SD, et al：Prasugrel versus clopidogrel in patients with acute coronary syndromes. N Engl J Med 357：2001-2015, 2007

20）Saito S, et al：Efficacy and safety of adjusted-dose prasugrel compared with clopidogrel in japanese patients with acute coronary syndrome. Circ J 78：1684-1692, 2014

21）Ohya M, et al：In-hospital bleeding and utility of a maintenance dose of prasugrel 2.5 mg in high bleeding risk patients with acute coronary syndrome. Circ J 82：1874-1883, 2018

22）Sung JJ, et al：Continuation of low-dose aspirin therapy in peptic ulcer bleeding；A randomized trial. Ann Intern Med 152：1-9, 2010