每日一题_2022.2.7

A 72-year-old man is admitted to the ICU following evaluationin the emergency department for a three-hour history of pressure-like substernal chest pain with dyspnea(呼吸困难). ECG reveals new T-wave inversions（倒置） in the inferior leads. Troponin-I levels are 0.04 ng/ml and then 0.06 ng/ml (normal range <0.01 ng/ml). Cardiac catheterization reveals 90% occlusion of the proximal left anterior descending artery, proximal OM1, and mid-right coronary artery. He undergoes urgent six-vessel coronary artery bypass graft without complication.

Which of the following is the most appropriate management of his antiplatelet therapy on arrival to the ICU?

A. Start aspirin and clopidogrel.

B. Start aspirin only.

C. Start clopidogrel only.

D. There is no indication for antiplatelet therapy at this time.

补充内容：

Antiplatelet Therapy Recommendations抗血小板

1. Aspirin should be administered preoperatively and within 6 hours after CABG in doses of 81 to 325 mg daily. It should then be continued indefinitely to reduce graft occlusion and adverse cardiac events (Class I; Level of Evidence A).围手术期和 CABG 后 6 小时内应给予阿司匹林，81-325m9, 每日一次。阿司匹林应无限期给予，以降低旁路血管堵塞和心血管不良事件。
2. After off-pump CABG, dual antiplatelet should be administered for 1 year with combined aspirin (81– 162 mg daily) and clopidogrel 75 mg daily to reduce graft occlusion (Class I; Level of Evidence A).非体外循环 CABG 后给予阿司匹林（81-162mg，每日一次）和氯吡格雷双联抗血小板治疗。
3. Clopidogrel 75 mg daily is a reasonable alternative after CABG for patients who are intolerant of or allergic to aspirin. It is reasonable to continue it indefinitely (Class IIa; Level of Evidence C).对于不耐受阿司匹林或对阿司匹林过敏的 CABG 患者，使用每日一次 75mg 氯吡格雷替代是合理的，可以无限期地服用。
4. In patients who present with acute coronary syndrome, it is reasonable to administer combination antiplatelet therapy after CABG with aspirin and either prasugrel or ticagrelor (preferred over clopidogrel), although prospective clinical trial data from CABG populations are not yet available (Class IIa; Level of Evidence B). 对于急性冠脉综合征患者，尽管缺少 CABG 人群的前瞻的数据，但 CABG 后给予阿司匹林和普拉格雷或替格瑞洛（首选氯吡格雷）联合抗血小板治疗是合理的。
5. As sole antiplatelet therapy after CABG, it is reasonable to consider a higher aspirin dose (325 mg daily) rather than a lower aspirin dose (81 mg daily), presumably to prevent aspirin resistance, but the benefits are not well established (Class IIa; Level of Evidence A).CABG 后单一抗血小板治疗时，为预防阿司匹林抵抗，可以考虑使用大剂量（325mg）的阿司匹林而不是低剂量（81mg），但相关获益尚未明确。
6. Combination therapy with both aspirin and clopidogrel for 1 year after on-pump CABG may be considered in patients without recent acute coronary syndrome, but the benefits are not well established (Class IIb; Level of Evidence Level A).对于近期无急性冠脉综合征而行体外循环 CABG 的患者，可以考虑阿司匹林和氯吡格雷双联抗血小板治疗 1 年，但获益尚未明确。

Antithrombotic Therapy Recommendations抗凝治疗

1. Warfarin should not be routinely prescribed after CABG for graft patency unless patients have other indications for long-term antithrombotic therapy (such as AF, venous thromboembolism, or a mechanical prosthetic valve) (Class III; Level of Evidence A).CABG 后不需常规使用华法林，除非患者有其它的抗凝指征，如房颤、静脉血栓栓塞症或机械性瓣膜置换。
2. Antithrombotic alternatives to warfarin (dabigatran, apixaban, rivaroxaban) should not be routinely administered early after CABG until additional safety data have accrued (Class III; Level of Evidence C).CABG 早期不应常规使用替代华法林的抗凝药物（达比加群、阿哌沙班和利伐沙班），这些药物的安全性尚未完全明确。