Индивидуализация антитромбоцитарной терапии в эпоху клинических стандартов
Н.В. Ломакин

Ключевые слова

тромбоциты
антитромбоцитарная терапия
ишемическая болезнь сердца
тромбоз
кровотечения

Как цитировать

[1]
Н. Ломакин, Индивидуализация антитромбоцитарной терапии в эпоху клинических стандартов, КМКВ, вып. 3, дек. 2015.

Аннотация

Антитромбоцитарная терапия широко применяется для предотвращения тромботических событий у больных ссердечно-сосудистой патологией. Однако индивидуальный ответ на препараты этого ряда значительно различаетсяи может быть одной из причин повторных клинических событий, связанных как с тромбозом, так и кровотечением.Несмотря на большое число исследований, посвященных этой проблеме и опубликованных в последнее время,вопрос необходимости тестирования функциональной реактивности тромбоцитов в клинической практике остаетсяне до конца решенным. Возможность применения тестирования тромбоцитов у отдельных групп сердечно-сосудистыхбольных рассмотрена в клинических рекомендациях, осуществлены попытки систематизации данных в рядеконсенсусов экспертов ведущих научных сообществ. Вместе с этим имеющиеся подходы к проведению тестированияфункций тромбоцитов не до конца согласованы, не выработаны единые алгоритмы принятия решения, основанные напоказателях активности тромбоцитов, не определены четкие показания к исследованию. Данный документ представляетсобой заключение междисциплинарного Совета экспертов Российского общества ангиологов и сосудистых хирургов,Российского научного общества специалистов по рентгенэндоваскулярной диагностике и лечению, национальнойассоциации по борьбе с инсультами, Национального научного общества воспаления.The antiplatelet therapy is widely used to prevent thrombotic events in patients with cardiovascular pathology. However,an individual response to such therapy varies considerably and can be one of the causes of repeated clinical events, namely,thrombosis and bleeding. Despite of a large number of researches and publications on the discussed issue which have appearedrecently, the problem of functional testing of platelet reactivity in clinical practice is still not fully solved. Recently,platelet testing have been indicated for some groups of cardiovascular patients in clinical recommendations; there have alsobeen made attempts to systematize the data-base on the problem in a number of leading expert scientific communities. Atthe same time, the available approaches for testing the platelet function are not fully coordinated; there are no unified decision-making algorithms on platelet activity indicators as well as there are no clear indications for investigation procedures.The presented document is a conclusion of interdisciplinary Expert Council of Russian Society of Angiologists and VascularSurgeons, of Russian Scientific Society of specialists on endovascular diagnostics and treatment, of National Association forCombating Strokes and National Scientific Society of Inflammation.

Литература

1. Siller-Matula J. et al. Personalized antiplatelet
treatment after percutaneous coronary intervention: The
MADONNA study. J Cardiol. 2013; 167: 2018–2023.
2. Grove E. et al. Platelet function testing and prediction
of procedural bleeding risk. Thromb. Haemost. 2013; 109: 817–
824.
3. Мирзаев К. Б. и др. Оценка агрегации тромбоци-
тов в клинической практике. Рацион. фармакотер в кар-
диол. 2015; 11 (1): 85–91.
4. Perk J., De Backer G., Gohlke H. et al. European
Guidelines on cardiovascular disease prevention in
clinicalpractice (version 2012). Eur. Heart J. 2012; 33: 1635–
1701.
5. Gorog D., Fuster V. Platelet Function Tests in Clinical
Cardiology. J. Am. Coll. Cardiol. 2013; 61 (21): 2115–2129.
6. Brar S. et al. Impact of platelet reactivity on clinical
outcomes after percutaneous coronary intervention. A
collaborative meta-analysis of individual participant data. J.
Am. Coll. Cardiol. 2011; 58: 1945–1954.
7. Cecchi E. et al. Dual antiplatelet therapy tailored on
platelet function test after coronary stent implantation: a realworld
experience. Intern. Emerg. Med. 2015; 1–10.
8. Wang X. et al. Modifying clopidogrel maintaince
doses according to vasodilatator-stimulated phosphoprotein
phochorylation index improves clinical outcome in patients with
clopidogrel resistance. Clin. Cardiol. 2011; 3495: 332–338.
9. Bonello L. et al. Tailored clopidogrel loading
doseaccording to platelet reactivity monitoring to prevent acute
and subacute stent thrombosis. Am. J. Cardiol. 2009; 103 (1):
5–10.
10. Valgimigli M. et al. Tailoring treatment with tirofiban
in patients showing resistance to aspirin and/or resistance to
clopidogrel (3T/2R) investigators. Circulation. 2009; 119 (5):
3215–3222.
11. Ari H. et al. The EFFect of high-dose Clopidogrel
treatment in patients with clopidogrel resistanse (the
EFFICIENT trial). Int. J. Cardiol. 2012; 157 (3): 374–380.
12. Stone G. et al. Platelet reactivity and clinical
outcomes after coronary artery implantation of drug-eluting
stents (ADAPT-DES): a prospective multicentre registry study.
Lancet. 2013; 382: 614–623.
13. Christ G. et al. Open Individualising dual antiplatelet
therapy after percutaneous coronary intervention: the IDEALPCI
registry. BMJ open. 2014; 4 (10): e005781.
14. Breet N. et al. Comparison of platelet function tests
in predicting clinical outcome in patients undergoing coronary
stent implantation.JAMA. 2010; 303 (8): 754–762.
15. Mangiacapra F. et al. A therapeutic window for
platelet reactivity for patients undergoing elective percutaneous
coronary intervention. Results of the ARMYDA-PROVE
(Antiplatelet therapy for Reduction of Myocardial Damage
during Angioplasty–Platelet Reactivity for Outcome Validation
Effort) study. JACC: cardiovascular interventions. 2012; 5 (3):
281–289.
16. Parodi G. et al. High Residual Platelet Activity After
Clopidogrel Loading and Long-term Cardiovascular Events
Among Patients With Acute Coronary Syndromes Undergoing
PCI. JAMA. 2011; 306 (11): 1215–1223.
17. Aradi D. et al. Optimazing P2Y12 receptor inhibition
in patients with acute coronary syndrome on the basis of platelet
function testing: impact of prasugrel and high-dose clopidogrel.
JACC. 2014; 11: 1061–1070.
18. Aradi D. et al. Platelet function testing in acute cardiac
care – is there a role for prediction or prevention of stent
thrombosis and bleeding? Thromb Haemostas. 2015; 113 (2):
221–230.
19. Sibbing D. et al. High platelet reactivity and clinical
outcome –Fact and fiction. Thromb Haemost. 2011; 106 (2):
191–202.
20. Price M. J. et al. Standard-vs high-dose clopidogrel
based on platelet function testing after percutaneous coronary
intervention: the GRAVITAS randomized trial. Jama. 2011; 305
(11): 1097–1105.
21. Trenk D. et al. A randomized trial of prasugrel versus
clopidogrel in patients with high platelet reactivity on clopidogrel
after elective percutaneous coronary intervention with
implantation of drug-eluting stents: results of the TRIGGERPCI
(Testing Platelet Reactivity In Patients Undergoing Elective
Stent Placement on Clopidogrel to Guide Alternative Therapy
With Prasugrel) study. J Amer Coll Cardiol. 2012; 59 (24):
2159–2164.
22. Collet J. et al. Randomized comparison of platelet
function monitoring to adjust antiplatelet therapy versus
standard of care: rationale and design of the assessment with a
double randomization of (1) a fixed dose versus a monitoringguided
dose of aspirin and clopidogrel after DES implantation,
and (2) treatment interruption versus continuation, 1 year after
stenting (ARCTIC) study. Amer Heart J. 2011; 161 (1): 5–12.
23. Aradi D. et al. Bleeding and stent thrombosis on P2Y12-
inhibitors: collaborative analysis on the role of platelet reactivity
for risk stratification after percutaneous coronary intervention.
Eur Heart J. 2015; ehv104 (в печати).
24. Angiolillo D. et al. Impact of platelet reactivity on
cardiovascular outcomes in patients with type 2 diabetes mellitus
and coronary artery disease. J Am Coll Cardiol. 2007; 50:
1541–1547.
25. Park S. et al. A comparison of clopidogrel responsiveness
in patients with versus without chronic renal failure. AmJCardiol.
2009; 104: 1292–1295.
26. Li-Wan-Po Aet al. Pharmacogenetics of CYP2C19:
functional and clinical implications of a new variant
CYP2C19*17. Br J Clin Pharmacol. 2010; 69 (3): 222–230.
27. Sibbing D. et al. Cytochrome P450 2C19 lossof-
function polymorphism and stent thrombosis following
percutaneous coronary intervention. Eur Heart J. 2009; 30 (8):
916–922.
28. Varenhorst C.et al. Ticagrelor plasma levels but not
clinical outcomes are associated with transporter and metabolism
enzyme genetic polymorphisms. J Am Coll Cardiol. 2014; 63
(12S).
29. Алекян Б. Г. с соавт. Роль тестирования функ-
циональной активности тромбоцитов в профилактике
сердечно-сосудистых осложнений у больных, получающих
антитромбоцитарную терапию. Рацион фармакотер в
кардиол. 2014; 10 (6): 679–687.
30. Chinese Society of Cardiology of Chinese Medical
Association et al. Chinese experts recommendation on the
monitoring and management of variability in responsiveness to
antiplatelet therapy //European Heart Journal Supplements.
2015; 17 (suppl B): B5–B12.
31. Fitchett D. et al. Antiplatelet therapy and cardiac
surgery: Review of recent evidence and clinical implications.
Canadian J Cardiol. 2013; 29 (9): 1042–1047.