Статья
Антитромботическая терапия у пациентов с фибрилляцией предсердий при чрескожных коронарных вмешательствах
Всесторонняя защита пациента с фибрилляцией предсердий (ФП) должна обеспечивать не только снижение риска инсульта и системной эмболии, но и снижение риска коронарных событий и высокую приверженность лечению. Согласно рекомендациям Европейской ассоциации сердечного ритма, Европейского общества кардиологов, Европейской ассоциации по чрескожным сердечно-сосудистым вмешательствам, Американской коллегии кардиологов, а также недавних рекомендаций Российского кардиологического общества антитромботическая терапия у пациентов с ФП, подвергающихся чрескожному коронарному вмешательству (ЧКВ), требует решения ряда сложных и взаимосвязанных вопросов. В обзорной статье рассмотрены вопросы продолжительности начальной тройной антитромботической терапии (ТАТ), выбор ингибитора P2Y12 рецепторов тромбоцитов, выбор перорального антикоагулянта в сочетании с антитромбоцитарной терапией, интенсивность пероральной антикоагуляции и выбор перорального антикоагулянта для длительной терапии. В целом рекомендуется отказаться от рутинного применения ТАТ для большинства пациентов. Для пациентов, нуждающихся как в антикоагулянтной, так и в антиагрегантной терапии настоятельно рекомендуется, чтобы стратегией по умолчанию после недавнего ЧКВ была двойная антитромботическая терапия, состоящая из антикоагулянта и одного антиагреганта, предпочтительно – из группы ингибиторов P2Y12. При проведении комбинированной антитромботической терапии предпочтение следует отдавать клопидогрелу по сравнению с другими, более мощными ингибиторами P2Y12 и прямым оральным антикоагулянтом (ПОАК) вместо антагонистов витамина К. Первичный выбор ПOAК у пациентов с ФП, перенесших ЧКВ, должен осуществляться с учетом таких факторов, как индивидуальный риск инсульта и кровотечения, приверженность лечению, сопутствующие заболевания, фармакологические характеристики и доказательная база конкретного ПОАК, прием других медикаментов и т.п. Фармакокинетические особенности ривароксабана, создающие возможность его однократного приема, доказательная база в отношении снижения коронарных рисков при различных вариантах течения ишемической болезни сердца определяет особые позиции препарата для всесторонней защиты пациентов с ФП после ЧКВ.
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