Tạp chí Tim mạch học Việt Nam

Chi tiết bài viết

Mô tả chi tiết bài viết

Trang chủ
BÀI TỔNG QUAN. Số phát hành: Số 117

Có gì mới trong các hướng dẫn về thuốc kháng đông trong can thiệp mạch vành qua da

Trương Quang Bình: BV ĐH Y Dược TP. Hồ Chí Minh;
Xuất bản: tháng 9 30, 2025
Views: 48
DOI 10.58354/jvc.117.2025.956

Tóm tắt

Đặt vấn đề: Thuốc kháng đông đường tĩnh mạch là nền tảng trong can thiệp mạch vành qua da (PCI), giúp giảm biến cố huyết khối trong và sau thủ thuật. Tuy nhiên, việc sử dụng cần cân bằng giữa hiệu quả chống huyết khối và nguy cơ chảy máu.

Phương pháp: Bài viết tổng quan, phân tích các bằng chứng gần đây và so sánh khuyến cáo từ các hướng dẫn quốc tế (ACC/AHA 2025, ESC 2023), tập trung vào lựa chọn, liều lượng và chỉ định của các thuốc kháng đông trong PCI, bao gồm UFH, heparin trọng lượng phân tử thấp, bivalirudin, fondaparinux và enoxaparin.

Kết quả: Kháng đông được khuyến cáo cho tất cả bệnh nhân hội chứng vành cấp, với UFH hoặc bivalirudin là lựa chọn ưu tiên trong STEMI và NSTE-ACS. Ở bệnh nhân có rung nhĩ hoặc đang dùng kháng đông mạn, việc lựa chọn thuốc và thời điểm ngưng/khởi động lại rất quan trọng để giảm cả nguy cơ chảy máu lẫn huyết khối. Rung nhĩ mới khởi phát sau PCI làm tăng nguy cơ tử vong và đột quỵ, cần chiến lược kháng đông phù hợp.

Kết luận: Không có thuốc kháng đông nào tối ưu cho mọi bệnh nhân PCI. Lựa chọn cần được cá thể hóa dựa trên bối cảnh lâm sàng, nguy cơ xuất huyết – huyết khối và chức năng thận.

Từ khóa
Kháng đông tĩnh mạch can thiệp mạch vành qua da hội chứng vành cấp nguy cơ chảy máu cá thể hóa điều trị

Tài liệu tham khảo

1.
Généreux P, Stone GW, Harrington RA, et al. Impact of Intraprocedural Stent Thrombosis During Percutaneous Coronary Intervention: Insights From the CHAMPION PHOENIX Trial (Clinical Trial Comparing Cangrelor to Clopidogrel Standard of Care Therapy in Subjects Who Require Percutaneous Coronary Intervention). Journal of the American College of Cardiology. 2014;63(7):619–629.
DOI: doi.org/10.1016/s0735-1097(14)61817-9
2.
Writing Committee Members, Lawton JS, Tamis-Holland JE, et al. 2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. J Am Coll Cardiol. 2022;79(2):e21–e129.
3.
Neumann F-J, Sousa-Uva M, Ahlsson A, et al. 2018 ESC/EACTS Guidelines on myocardial revascularization. Eur Heart J. 2019;40(2):87–165.
4.
Montalescot G, Gallo R, White HD, et al. Enoxaparin versus unfractionated heparin in elective percutaneous coronary intervention 1-year results from the STEEPLE (SafeTy and efficacy of enoxaparin in percutaneous coronary intervention patients, an international randomized evaluation) trial. JACC Cardiovasc Interv. 2009;2(11):1083–1091.
5.
Schulz S, Mehilli J, Ndrepepa G, et al. Bivalirudin vs. unfractionated heparin during percutaneous coronary interventions in patients with stable and unstable angina pectoris: 1-year results of the ISAR-REACT 3 trial. Eur Heart J. 2010;31(5):582–587.
DOI: doi.org/10.15829/1560-4071-2019-8-151-226
6.
Efficacy and Safety of Subcutaneous Enoxaparin in Unstable Angina and Non-Q-wave MI [Internet]. American College of Cardiology. [cited 2025 Aug 23]. Available from: https://www.acc.org/latest-in-cardiology/clinical-trials/2010/02/23/19/03/http%3a%2f%2fwww.acc.org%2flatest-in-cardiology%2fclinical-trials%2f2010%2f02%2f23%2f19%2f03%2fessence.
7.
Antman EM. TIMI 11B. Enoxaparin versus unfractionated heparin for unstable angina or non-Q-wave myocardial infarction: a double-blind, placebo-controlled, parallel-group, multicenter trial. Rationale, study design, and methods. Thrombolysis in Myocardial Infarction (TIMI) 11B Trial Investigators. Am Heart J. 1998;135(6 Pt 3 Su):S353-360.
8.
Rokos IC. Enoxaparin versus heparin: the SYNERGY trial from an emergency medicine perspective. Drugs. 2005;65(10):1313–1316.
9.
Mehta SR, Granger CB, Eikelboom JW, et al. Efficacy and safety of fondaparinux versus enoxaparin in patients with acute coronary syndromes undergoing percutaneous coronary intervention: results from the OASIS-5 trial. J Am Coll Cardiol. 2007;50(18):1742–1751.
DOI: doi.org/10.1093/eurheartj/ehq008
10.
Erlinge D, Omerovic E, Fröbert O, et al. Bivalirudin versus Heparin Monotherapy in Myocardial Infarction. New England Journal of Medicine. 2017;377(12):1132–1142.
11.
Valgimigli M, Frigoli E, Leonardi S, et al. Bivalirudin or Unfractionated Heparin in Acute Coronary Syndromes. New England Journal of Medicine. 2015;373(11):997–1009.
12.
Assessment of the Safety and Efficacy of a New Thrombolytic Regimen (ASSENT)-3 Investigators. Efficacy and safety of tenecteplase in combination with enoxaparin, abciximab, or unfractionated heparin: the ASSENT-3 randomised trial in acute myocardial infarction. Lancet. 2001;358(9282):605–613.
DOI: doi.org/10.1016/s0002-8703(98)70265-0
13.
Antman EM, Morrow DA, McCabe CH, et al. Enoxaparin versus Unfractionated Heparin with Fibrinolysis for ST-Elevation Myocardial Infarction. New England Journal of Medicine. 2006;354(14):1477–1488.
14.
Montalescot G, Zeymer U, Silvain J, et al. Intravenous enoxaparin or unfractionated heparin in primary percutaneous coronary intervention for ST-elevation myocardial infarction: the international randomised open-label ATOLL trial. The Lancet. 2011;378(9792):693–703.
DOI: doi.org/10.2165/00003495-200565100-00001
15.
The OASIS-6 Trial Group*. Effects of Fondaparinux on Mortality and Reinfarction in Patients With Acute ST-Segment Elevation Myocardial InfarctionThe OASIS-6 Randomized Trial. JAMA. 2006;295(13):1519–1530.
16.
Shahzad A, Kemp I, Mars C, et al. Unfractionated heparin versus bivalirudin in primary percutaneous coronary intervention (HEAT-PPCI): an open-label, single centre, randomised controlled trial. The Lancet. 2014;384(9957):1849–1858.
17.
Henriques JPS, Zijlstra F, Ottervanger JP, et al. Incidence and clinical significance of distal embolization during primary angioplasty for acute myocardial infarction. Eur Heart J. 2002;23(14):1112–1117.
18.
Angiolillo DJ, Bhatt DL, Cannon CP, et al. Antithrombotic Therapy in Patients With Atrial Fibrillation Treated With Oral Anticoagulation Undergoing Percutaneous Coronary Intervention. Circulation. 2021;143(6):583–596.
19.
Verheugt FWA, Steinhubl SR, Hamon M, et al. Incidence, prognostic impact, and influence of antithrombotic therapy on access and nonaccess site bleeding in percutaneous coronary intervention. JACC Cardiovasc Interv. 2011;4(2):191–197.
20.
Mehran R, Pocock SJ, Nikolsky E, et al. A risk score to predict bleeding in patients with acute coronary syndromes. J Am Coll Cardiol. 2010;55(23):2556–2566.
21.
Damluji AA, Otalvaro L, Cohen MG. Anticoagulation for percutaneous coronary intervention: a contemporary review. Curr Opin Cardiol. 2015;30(4):311–318.
22.
Rao SV, O’Donoghue ML, Ruel M, et al. 2025 ACC/AHA/ACEP/NAEMSP/SCAI Guideline for the Management of Patients With Acute Coronary Syndromes: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation. 2025;151(13):e771–e862.
23.
The Fifth Organization to Assess Strategies in Acute Ischemic Syndromes Investigators. Comparison of Fondaparinux and Enoxaparin in Acute Coronary Syndromes. New England Journal of Medicine. 2006;354(14):1464–1476.
24.
Byrne RA, Rossello X, Coughlan JJ, et al. 2023 ESC Guidelines for the management of acute coronary syndromes. Eur Heart J. 2023;44(38):3720–3826.
DOI: doi.org/10.1056/nejmoa060898
25.
O’Gara PT, Kushner FG, Ascheim DD, et al. 2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation. 2013;127(4):e362-425.
26.
Amsterdam EA, Wenger NK, Brindis RG, et al. 2014 AHA/ACC Guideline for the Management of Patients with Non-ST-Elevation Acute Coronary Syndromes: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2014;64(24):e139–e228.
DOI: doi.org/10.1016/s0140-6736(11)60876-3
27.
Thygesen K, Alpert JS, Jaffe AS, et al. Fourth Universal Definition of Myocardial Infarction (2018). Journal of the American College of Cardiology. 2018;72(18):2231–2264.
28.
Zeymer U, Rao SV, Montalescot G. Anticoagulation in coronary intervention. Eur Heart J. 2016;37(45):3376–3385.
29.
Kw M, Be L, Nm W, et al. The anticoagulant therapy with bivalirudin to assist in the performance of percutaneous coronary intervention in patients with heparin-induced thrombocytopenia (ATBAT) study: main results. The Journal of invasive cardiology [Internet]. 2003 [cited 2025 Aug 23];15(11).
30.
Be L, Wh M, M C, et al. Argatroban anticoagulation during percutaneous coronary intervention in patients with heparin-induced thrombocytopenia. Catheterization and cardiovascular interventions : official journal of the Society for Cardiac Angiography & Interventions [Internet]. 2002 [cited 2025 Aug 23];57(2).
DOI: doi.org/10.1016/s0140-6736(14)60924-7
31.
Bahit MC, Topol EJ, Califf RM, et al. Reactivation of ischemic events in acute coronary syndromes: results from GUSTO-IIb. Journal of the American College of Cardiology. 2001;37(4):1001–1007.
32.
Granger CB, Miller JM, Bovill EG, et al. Rebound increase in thrombin generation and activity after cessation of intravenous heparin in patients with acute coronary syndromes. Circulation. 1995;91(7):1929–1935.
DOI: doi.org/10.1053/euhj.2001.3035
33.
Verheugt FWA, Granger CB. Oral anticoagulants for stroke prevention in atrial fibrillation: current status, special situations, and unmet needs. Lancet. 2015;386(9990):303–310.
34.
Valgimigli M, Frigoli E, Leonardi S, et al. Bivalirudin or Unfractionated Heparin in Acute Coronary Syndromes. N Engl J Med. 2015;373(11):997–1009.
DOI: doi.org/10.1161/circulationaha.120.050438
35.
Angiolillo DJ. Vascular access and antithrombotic therapy in patients with acute coronary syndrome. Lancet. 2018;392(10150):801–802.
36.
Stone GW, Witzenbichler B, Guagliumi G, et al. Bivalirudin during primary PCI in acute myocardial infarction. N Engl J Med. 2008;358(21):2218–2230.
DOI: doi.org/10.1016/j.jcin.2010.10.011
37.
Olsen A-MS, McGettigan P, Gerds TA, et al. Risk of gastrointestinal bleeding associated with oral anticoagulation and non-steroidal anti-inflammatory drugs in patients with atrial fibrillation: a nationwide study. Eur Heart J Cardiovasc Pharmacother. 2020;6(5):292–300.
38.
Ray WA, Chung CP, Murray KT, et al. Association of Oral Anticoagulants and Proton Pump Inhibitor Cotherapy With Hospitalization for Upper Gastrointestinal Tract Bleeding. JAMA. 2018;320(21):2221–2230.
DOI: doi.org/10.1016/j.jacc.2009.09.076
39.
Kalarus Z, Svendsen JH, Capodanno D, et al. Cardiac arrhythmias in the emergency settings of acute coronary syndrome and revascularization: an European Heart Rhythm Association (EHRA) consensus document, endorsed by the European Association of Percutaneous Cardiovascular Interventions (EAPCI), and European Acute Cardiovascular Care Association (ACCA). Europace. 2019;21(10):1603–1604.
40.
Lee JH, Kim S-H, Lee W, et al. New-onset paroxysmal atrial fibrillation in acute myocardial infarction: increased risk of stroke. BMJ Open. 2020;10(9):e039600.
DOI: doi.org/10.1097/hco.0000000000000182
41.
Zeng Q, Li W, Luo Z, et al. The role of miR1 and miR133a in new-onset atrial fibrillation after acute myocardial infarction. BMC Cardiovasc Disord. 2023;23(1):448.
42.
Fukunami M. Transient Atrial Fibrillation During Acute Myocardial Infarction Is a Predictor of Poor Outcomes. Circ J. 2016;80(7):1534–1536.
43.
Petersen JK, Butt JH, Yafasova A, et al. Prognosis and antithrombotic practice patterns in patients with recurrent and transient atrial fibrillation following acute coronary syndrome: A nationwide study. International Journal of Cardiology. 2024;407:132017.
44.
Li J, Becker R, Rauch B, et al. Usefulness of Heart Rate to Predict One-Year Mortality in Patients With Atrial Fibrillation and Acute Myocardial Infarction (from the OMEGA Trial). The American Journal of Cardiology. 2013;111(6):811–815.
45.
Van Gelder IC, Rienstra M, Bunting KV, et al. 2024 ESC Guidelines for the management of atrial fibrillation developed in collaboration with the European Association for Cardio-Thoracic Surgery (EACTS): Developed by the task force for the management of atrial fibrillation of the European Society of Cardiology (ESC), with the special contribution of the European Heart Rhythm Association (EHRA) of the ESC. Endorsed by the European Stroke Organisation (ESO). Eur Heart J. 2024;45(36):3314–3414.
46.
Raczkowska-Golanko M, Młodziński K, Raczak G, et al. New-Onset Atrial Fibrillation in Acute Myocardial Infarction Is a Different Phenomenon than Other Pre-Existing Types of That Arrhythmia. Journal of Clinical Medicine. 2022;11(15):4410.
DOI: doi.org/10.1093/eurheartj/ehad863
47.
Kundu A, O’Day K, Shaikh AY, et al. Relation of Atrial Fibrillation in Acute Myocardial Infarction to In-Hospital Complications and Early Hospital Readmission. The American Journal of Cardiology. 2016;117(8):1213–1218.
48.
Petersen JK, Butt JH, Yafasova A, et al. Incidence of ischaemic stroke and mortality in patients with acute coronary syndrome and first-time detected atrial fibrillation: a nationwide study. Eur Heart J. 2021;42(44):4553–4561.
49.
Rene AG, Généreux P, Ezekowitz M, et al. Impact of Atrial Fibrillation in Patients With ST-Elevation Myocardial Infarction Treated With Percutaneous Coronary Intervention (from the HORIZONS-AMI [Harmonizing Outcomes With Revascularization and Stents in Acute Myocardial Infarction] Trial). The American Journal of Cardiology. 2014;113(2):236–242.
50.
Luo J, Liu B, Li H, et al. Prognostic Impact of the Symptom of New-Onset Atrial Fibrillation in Acute Myocardial Infarction: Insights From the NOAFCAMI-SH Registry. Front Cardiovasc Med. 2021;8:677695.
51.
Wang C-L, Chen P-C, Juang H-T, et al. Adverse Outcomes Associated with Pre-Existing and New-Onset Atrial Fibrillation in Patients with Acute Coronary Syndrome: A Retrospective Cohort Study. Cardiol Ther. 2019;8(1):117–127.
52.
Yi J-E, Seo S-M, Lim S, et al. Gender Differences in the Impact of New-Onset Atrial Fibrillation on Long-Term Risk of Ischemic Stroke after Acute Myocardial Infarction. Journal of Clinical Medicine. 2021;10(21):5141.
DOI: doi.org/10.1161/cir.0000000000000617
53.
Lehto M, Snapinn S, Dickstein K, et al. Prognostic risk of atrial fibrillation in acute myocardial infarction complicated by left ventricular dysfunction: the OPTIMAAL experience. Eur Heart J. 2005;26(4):350–356.

Tệp

PDF
Lượt xem bài48
Lượt xem tài liệu0
Lượt tải xuống0
Chuyên mục BÀI TỔNG QUAN.
Số phát hành Số 117
Trang 29-42