Lamberts及同事在心肌梗死（MI）后或经皮冠状动脉介入治疗（PCI）后的心房颤动（AF）患者中，研究多重抗栓治疗方案的血栓形成和出血风险。纳入12 165例因MI住院或接受PCI的AF患者，并根据抗栓治疗方案评估MI/冠心病死亡、缺血性卒中和出血风险。1年内，分别有2255例（18.5%）、680例（5.6%）和756例（6.3%）患者发生MI或冠心病死亡、缺血性卒中和出血事件。相对于三联疗法（口服抗凝药物[OAC]+阿司匹林+氯吡格雷），OAC+氯吡格雷、OAC+阿司匹林或阿司匹林+氯吡格雷疗法未见冠状动脉事件复发风险增加，但阿司匹林+氯吡格雷导致缺血性卒中风险较高。与三联疗法相比，OAC+氯吡格雷的出血风险非显著性降低，阿司匹林+氯吡格雷则显著降低。作者总结，在临床实际情况中，对MI/ PCI后有多重抗栓治疗适应证的AF患者，OAC+氯吡格雷与三联疗法相比在获益和安全性结果方面相等或更好。

　　J Am Coll Cardiol. 2013;62(11):981-989.

　　特邀点评

　　Add-on Antiplatelet Therapy in Atrial Fibrillation Patients on Warfarin after Myocardial Infarction or Coronary Intervention.

　　比利时布鲁塞尔Brugmann大学医院  Safouris Apostolos

　　Adding one or two antiplatelet agents on top of oral anticoagulation (OAC) is the current standard of care for atrial fibrillation (AF) patients post myocardial infarction (MI) or percutanous coronary intervention (PCI). The well-known excess bleeding risk of double or triple antithrombotic treatment is considered a rational trade-off for myocardial re-infarction or stent thrombosis in the acute phase but there is accumulating evidence that prolonged treatment comes with serious bleeding complications that could diminish any potential (and still unproven) benefit.  Current guidelines from the European Society of Cardiology Working Group on Thrombosis for the antithrombotic treatment post PCI of non-valvular AF patients necessitating anticoagulation advocate triple antithrombotic treatment for 2 weeks up to 6 months depending on stent type (drug eluting or not)， bleeding risk and the whether the intervention was elective or performed in an acute setting. These recommendations are only based on nonrandomized studies but data is growing that prolonged triple antithrombotic treatment could be deleterious. In the September issue of the Journal of the American College of Cardiology， Lamberts et al. assessed the risk of thrombosis and bleeding of many antithrombotic regimens in AF patients post MI or PCI. The authors performed a retrospective analysis of the Danish National Patient Registry and identified more than 12，000 AF patients hospitalized for MI and/or undergoing PCI between 2001 and 2009. Aspirin， clopidogrel and OAC monotherapy， double antiplatelet therapy， double antithrombotic therapy (OAC plus aspirin or clopidogrel) and triple antithrombotic therapy (OAC plus clopidogrel plus aspirin) were evaluated for hemorrhagic or thrombotic complications at one year after initiation of therapy. The main finding was that there seems to be no benefice in adding aspirin to OAC plus clopidogrel. The authors concluded that triple antithrombotic therapy could be safely replaced by OAC and clopidogrel.

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