2) ANTIAGGREGANTI e WARFARIN
Safety
and efficacy of Aspirin, Clopidogrel and warfarin after coronary stent
placement in patients with an indication for anticoagulation.
Studio osservazionale in 65 pz-Il rischio emorragico della combinazione dei 3 farmaci (9,2%) è più elevato rispetto al clopidogrel (1,8%), all’ASA+warfarin (6,5%)
POSSIBILI OPZIONI TERAPEUTICHE:
Poiché il rischio di trombosi dello stent è più elevato nelle prime 2 settimane dopo il posizionamento, si potrebbe sospendere l’associazione di due antiaggreganti dopo 2 settimane e proseguire con warfarin+ aggregante singolo.
La sospensione del tienopiridinico aumenta il rischio di reinfarto e morte del 50%., pertanto se il pz era in trattamento con ASA si potrebbe sospenderla temporaneamente e abbinare warfarin e tienopiridinico.
La sostituzione del warfarin con eparina a basso peso molecolare (0,5 mg/Kg enoxaparina+clopidogrel+ASA) nei pz con indicazione a warfarin non è suffragata da studi. Potrebbe avere un rischio emorragico maggiore rispetto al doppio antiaggregante.
Combination antithrombotic
therapy with
antiplatelet agents and anticoagulants for patients with
atherosclerotic heart
disease.
J Invasive Cardiol 2004,16,271-metanalisi
La terapia combinata aumenta il rischio di emorragie minori e leggermente le emorragie maggiori, ma non le emorragie intracraniche.
Bleeding
complications associated with combinations of aspirin,thienopyridine
derivatives, and warfarin in elderly patients following acute
myocardial
infarction. Buresly K
Arch Intern Med 2005, April 11, 165, 784-9
Studio su 21443 pz anziani post IMA. 7% die pz hanno avuto ricovero x emorragia.
ASA 0,03% anno
ASA+ tienopiridinico 0,07% anno OR 1,65 rispetto a sola ASA
ASA+ tienopiridinico+ warfarin 0,09% anno OR 1,92
Quindi
complessivamente rischio basso.
Aspirin,
Warfarin and a Thienopyridine for acute coronary syndromes. Konstantino
Y
Cardiology 2005, nov 9, 105 (2)
80-85
No differenza di mortalità tra doppia o tripla terapia a 30 gg e
a 6 mesi.
Su 5706 pz, 76 pz (1,3%) sottoposti a triplo trattamento. e 47% a
doppia antiaggregazione.
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Eur Heart J. 2007 Mar;28(6):726-32. Epub 2007 Jan 31.
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Safety and efficacy of combined antiplatelet-warfarin therapy after coronary stenting.
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Department of Cardiology, Satakunta Central Hospital, Sairaalantie 3, 28100 Pori, Finland.
AIM: The aim of this study was to evaluate the antithrombotic treatment adopted after coronary stenting in patients requiring long-term anticoagulation. METHODS AND RESULTS: We analysed retrospectively all consecutive patients on warfarin therapy (n = 239, mean age 70 years, men 74%) who underwent percutaneous coronary intervention (PCI) in 2003-04 in six hospitals. An age- and sex-matched control group with similar disease presentation (unstable or stable symptoms) was selected from the study period. Primary endpoint was defined as the occurrence of death, myocardial infarction, target vessel revascularization, or stent thrombosis at 12 months. Warfarin treatment was an independent predictor of both primary endpoint (OR 1.7, 95% CI 1.0-3.0, P = 0.05) and major bleeding (OR 3.4, 95% CI 1.2-9.3, P = 0.02). Triple therapy with aspirin and clopidogrel was the most common (48%) option in stented patients in warfarin group, and there was a significant (P = 0.004) difference between the drug combinations in stent thrombosis with the highest (15.2%) incidence in patients receiving warfarin plus aspirin combination. CONCLUSION: Our study shows that the prognosis is unsatisfactory in warfarin-treated patients irrespective of the drug combination used. Aspirin plus warfarin combination seems to be inadequate to prevent stent thrombosis.
Marzo 2007