132В настоящее время фибрилляция предсердий (ФП) и сердечная недостаточность (СН) являются нарастающими эпидемиями, которые часто реги-стрируются одновременно или провоцируют воз-никновение друг друга. В недавней публикации, основанной на результатах проведенных регистров, показано, что примерно у 40% пациентов, госпита-лизированных по поводу СН, отмечалась в анамнезе ФП; до 50% пациентов имели исходную ФП, а при-мерно у 20% пациентов во время госпитализаций отмечалась впервые выявленная ФП [1]. В регистре EURObservational Research Programme: HF LongTerm Registry [2] было зарегистрировано наличие ФП у 44% пациентов, госпитализированных с острой и у 37,6% пациентов с хронической СН (ХСН). Встречаемость ФП у амбулаторных пациентов с ХСН обычно ниже и колеблется в пределах 2537%. Пациенты с комбинацией СН и ФП по сравнению с пациентами без ФП чаще старше, среди них больше женщин, реже отмечалась ишемическая болезнь сердца (ИБС), но чаще встречались клапанные пороки сердца и хронические несердечные заболе-вания [3].Частота встречаемости и распространенности ФП возрастают, даже с учетом поправки на старение популяции. Следует констатировать, что распростра-ненность СН увеличивается, поскольку оптимизация лечения улучшает выживаемость [4]. В целом, попу-ляция лиц с одновременным наличием ФП и СН постоянно увеличивается, поскольку эти состояния имеют общие факторы риска, каждое из них обладает предрасположенностью вызывать другое [5]. Так, наличие СН может быть как причиной возникнове-ния ФП, так и следствием течения этой аритмии (СН развивается намного чаще у пациентов с ФП, чем у пациентов без данного заболевания). The recent epidemiological data presented, on the prevalence, incidence of atrial fibrillation and comorbid heart failure. The main evidence provided on the risk increase for thromboembolic complications in this category of patients, efficacy data provided, as safety, of the direct oral anticoagulants in atrial fibrillation patients with heart failure, that might facilitate decisions on optimal anticoagulation for this category of patients. ФИБРИЛЛЯЦИЯ ПРЕДСЕРДИЙ И СЕРДЕЧНАЯ НЕДОСТАТОЧНОСТЬ: ПОДХОДЫ К АНТИТРОМБОТИЧЕСКОЙ ТЕРАПИИRuss J Cardiol 2017, 7 (147): 132-138 http://dx
The last decade has dramatically changed the strategy of anticoagulant therapy in patients with atrial fibrillation. Direct oral anticoagulants have replaced vitamin K antagonists: either direct thrombin blockers (dabigatran) or factor IIa blockers (apixaban, rivaroxaban, edoxaban). According to the regulatory domestic and foreign documents, the use of direct oral anticoagulants in patients with atrial fibrillation has priority in comparison with vitamin K antagonists, since they have a predictable anticoagulant effect, the possibility of taking fixed doses without the need for routine anticoagulant monitoring, rapid onset and termination of action, relatively low potential for food and drug interactions. Direct oral anticoagulants are used for the prevention of thromboembolic complications in patients with atrial fibrillation, for the prevention of deep vein thrombosis in patients who have undergone surgery on the knee or hip joints, for emergency treatment and secondary prevention of deep vein thrombosis and pulmonary embolism. Alertness to side effects tends to focus on the likelihood of bleeding, with the possibility of other side effects of direct oral anticoagulants receiving less attention or going unnoticed. These mainly include liver damage, kidney damage and a number of other rare adverse reactions. The finding of isolated thrombocytopenia in patients taking direct oral anticoagulants may be associated with a high risk of life-threatening bleeding. The article analyzes published data on the occurrence of thrombocytopenia associated with the intake of direct oral anticoagulants, and presents a clinical case of thrombocytopenia while taking apixaban.
The purpose of this review is to analyze the results of randomized clinical trials, meta-analyses of cohort and observational studies in real clinical practice on the influence of dabigatran etexilate on the risk of myocardial infarction in patients with atrial fibrillation. A pivotal RE-LY study on dabigatran use in patients with atrial fibrillation did not show statistically significant differences in the frequency of myocardial infarction between any of the doses of dabigatran and warfarin, and the risk of coronary events did not depend on the presence of coronary heart disease or myocardial infarction in the patient's history. Subsequently, a number of meta-analyses have reported an increased risk of myocardial infarction when dabigatran was administered to patients with atrial fibrillation. In general, these studies were characterized by conflicting data, which did not allow to draw any definite conclusions regarding the use of dabigatran in relation to the risk of myocardial infarction. Two FDA cohort observational studies were published in 2014 and 2017, and the former was significantly criticized by experts, and the results of the second study did not provide a definitive answer to the question about the importance of the effect of dabigatran on the development of myocardial infarction in patients with atrial fibrillation. Even more "confusing" the problem arose after the publication of meta-analyses of randomized trials, which showed that the risk of myocardial infarction was increased in patients treated with direct oral anticoagulants compared to patients treated with warfarin. This review provides high quality evidence for the efficacy of dabigatran in preventing myocardial infarction and other vascular complications in patients with atrial fibrillation.
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