NEJM：利伐沙班能降低心脏病患者死亡率

Matthew T. Roe, M.D., and E. Magnus Ohman, M.B., F.R.C.P.I.

During the past two decades, the use of antiplatelet therapies has been the focus of new studies of secondary prevention after acute coronary syndromes, with more than 75% of patients in contemporary practice treated with dual antiplatelet therapy (aspirin plus a thienopyridine) on hospital discharge. Despite increases in the use of antiplatelet therapies and the development of more potent antiplatelet therapies (prasugrel and ticagrelor), the residual risk of death,  myocardial infarction, or stroke up to 1 year after acute coronary syndromes remains high(Table 1NEJMe1112770&iid=t01">Rates of Ischemic and Bleeding Events in Drug Trials for Acute Coronary Syndrome.). This represents a therapeutic challenge, since the balance between risk (major bleeding) and benefit (reduction in ischemic events) becomes more delicate with time as the ischemic risk tends to diminish.The use of an anticoagulant, in addition to antiplatelet therapy, for secondary prevention has been explored in the past two decades with limited success. The first trials explored the use of warfarin with aspirin but did not show superiority, probably because of the challenges of maintaining a safe and adequate level of anticoagulation with warfarin. Subsequently, a low-molecular-weight heparin (dalteparin) versus placebo plus aspirin was tested in 1506 patients after hospitalization for an acute coronary syndrome. During the 6-week treatment phase, there was a significant reduction in the rate of a composite of death or myocardial infarction (P=0.04), and major bleeding events were rare. However, the treatment effect disappeared with longer-term follow-up, and subcutaneous administration limited the duration of treatment that could be tested.