Практическое руководство American Society of Gastrointestinal Endoscopy (98) по использованию антиагрегантов и антикоагулянтов под контролем ЖК эндоскопии GI рассматривает риски и пользу антиагрегационной терапии с использованием ЖК эндоскопии. Сердечно-сосудистые проблемы должны оставаться главными в ЖК практике эндоскописта; таким образом, сердечно-сосудистый риск перевешивает в клиническом принятии решения. В то же время много эндоскопистов предпочли бы отказаться от двойной антиагрегационной терапии под контролем плановой колоноскопии и полипэктомии,
фактическое свидетельство, что эта практика уменьшает риск постполипэктомического кровотечения, является крайним (98). Поэтому, мы поощряем эндоскопистов, рассматривать сердечно-сосудистые риски,
и отсрочить плановые процедуры у пациентов с высоким риском (например, с недавно установленными сердечно-сосудистыми стентами), например, в течение года после размещения drug-eluting стента. Важно подчеркнуть что руководство не призывает прекращать АСК или НПВП для большинства эндоскопических процедур из-за нехватки ясных данных, что эндоскопические процедуры, такие как полипэктомия неблагоприятно влияют на частоту кровотечений.
Наиболее вероятное решение проблемы возможного прекращения антиагрегантов у пациента с высоким риском возможно при проведении эндоскопической терапии при ЖК кровотечении. Это возможно не так часто, и снова главной должна быть индивидуальная стратификация риска. На основании консенсуса экспертов комитета авторов, тем, у кого хроническая потеря крови и высокий сердечно-сосудистый риск, такой как недавно помещенный стент, двойная антиагрегантная терапия должна быть продолжена как диктует сердечно-сосудистый риск, учитывая отстутствие ясно определенных противопоказаний к эндоскопическому вмешательству.
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В остром случае после успешного эндоскопического лечения большого ЖК кровоизлияния, будет благоразумным обсудить следующее, ненадолго прекратить антиагрегационную терапию, пока не убедимся, что нет ре-кровотечения в отделения интенсивной терапии. Оптимальная продолжительность прекращения антиагрегантной терапии, приводящая к равновесию ЖК и сердечно-сосудистые прогнозы, не была
установлена клиническими исследованиями. Текущая эффективность эндоскопической терапии при язвенном кровотечении в объединении с внутривенной непрерывной терапией ИПП предполагает повторное включение антиагрегантной терапии у пациентов с высоким сердечно-сосудистом риском, что разумно у тех, у кого нет ре-кровотечения после 3 - 7 дней (97). В намного менее частом случае эндоскопической терапии для кровотечения нижних отделов ЖКТ данные для принятия решения еще менее доступны. Там, где не ведется добавочная противоязвенная медикаментозная терапии ИНН при язвенном кровотечении,
эндоскописты могут использовать нетепловое лечение, такое как клиппирование и использовать паузу а антиагрегационной терапии в течение 7 - 10 дней, исходя из размера повреждения и индивидуальной
оценке адекватности эндоскопической терапии.
Резюме
У соответствующих пациентов пероральная антиагрегационная терапии уменьшает ишемические риски, но эта терапия может вызвать увеличение частоты кровотечений. Из возникающих больших кровотечений чаще всего случаются ЖК кровоизлияния. Сопутствующее использование НПВП еще больше повышает риск ЖК кровотечения. Гастропротекторная стратегии состоят из использования ИПП у пациентов с высоким риском ЖК кровотечения и эрадикация H.pylori у пациентов с язвенным анамнезом. Общение между кардиологами, гастроэнтерологами и врачами общей практики очень важно для того, чтобы взвесить ишемические риски и риски кровотечения индивидуально у каждого пациента, который нуждается в антиагрегационной терапии, но при этом существует опасность существенного ЖК кровотечения.
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Key Words: ACCF Expert Consensus Document y gastrointestinal risk
y antiplatelet therapy y NSAID y gastroduodenal ulcer y
gastrointestinal bleeding y aspirin y stents y thrombosis.