今日の臨床サポート

慢性期冠動脈疾患

著者: 後藤信哉 東海大学 内科学系循環器内科学

監修: 代田浩之 順天堂大学大学院医学研究科循環器内科学

著者校正/監修レビュー済:2021/09/29
患者向け説明資料

概要・推奨   

  1. 慢性期冠動脈疾患は全身の動脈硬化、血栓性病態の亢進した非可逆的病態であり、医療介入による予後改善効果は限られている。動脈硬化性変化が出現する前のリスク因子の段階における介入が重要である(推奨度1)。
  1. 冠動脈ステント留置後、アスピリンとクロピドグレルまたはプラスグレルのDAPTを1~3ヵ月間継続する(推奨度1)。
  1. 出血リスクが高い患者に対して、DAPT継続期間の1から3ヵ月への短期化を考慮する(推奨度1)。
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  1. 閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契
  1. 閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要
  1. 閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要とな
  1. 閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必 要となり
薬剤監修について:
オーダー内の薬剤用量は日本医科大学付属病院 薬剤部 部長 伊勢雄也 以下、林太祐、渡邉裕次、井ノ口岳洋、梅田将光による疑義照会のプロセスを実施、疑義照会の対象については著者の方による再確認を実施しております。
※薬剤中分類、用法、同効薬、診療報酬は、エルゼビアが独自に作成した薬剤情報であり、
著者により作成された情報ではありません。
尚、用法は添付文書より、同効薬は、薬剤師監修のもとで作成しております。
※薬剤情報の(適外/適内/⽤量内/⽤量外/㊜)等の表記は、エルゼビアジャパン編集部によって記載日時にレセプトチェックソフトなどで確認し作成しております。ただし、これらの記載は、実際の保険適用の査定において保険適用及び保険適用外と判断されることを保証するものではありません。また、検査薬、輸液、血液製剤、全身麻酔薬、抗癌剤等の薬剤は保険適用の記載の一部を割愛させていただいています。
(詳細はこちらを参照)
著者のCOI(Conflicts of Interest)開示:
後藤信哉 : 未申告[2021年]
監修:代田浩之 : 未申告[2021年]

改訂のポイント:
  1. 定期レビューを行い、「出血リスク、血栓リスクの層別化」「抗血小板併用療法の必要期間の短縮」「心房細動合併症における3剤併用リスク」について追記した。

病態・疫学・診察

疾患情報  
  1. 慢性期冠動脈疾患は、心筋を灌流する冠状動脈に動脈硬化性狭窄を認める疾患である。
 
慢性期冠動脈疾患と急性冠症候群の冠動脈病変

慢性期冠動脈疾患の冠動脈病変は動脈硬化巣による冠動脈狭窄が主病態である。このため、労作などにより心筋の酸素消費量が増加するときには十分な酸素供給ができずに胸痛が起こる。急性冠症候群では、冠動脈内の動脈硬化巣破綻部位に血栓を形成することが主病態である。急性冠症候群になると胸痛頻度の増加、胸痛を惹起する労作閾値の低下、安静時の胸痛などが起こる。

出典

img1:  著者提供
 
 
 
  1. 慢性期冠動脈疾患の診断では、労作時の胸痛について詳細な問診が必須である。
  1. 慢性期冠動脈疾患の症例では、冠動脈に動脈硬化性病変のない症例よりも、数年以内の近未来に心筋梗塞、脳卒中、心血管死亡などの心血管イベントを発症するリスクが高い。
  1. 慢性期冠動脈疾患では、脳卒中など冠動脈以外の血管(脳血管、末梢血管など)の動脈硬化、血栓イベントリスクが高い。
  1. 冠動脈における「動脈硬化性病変」の存在よりも、「心筋虚血症候」の有無を重視すること。無症候の「動脈硬化性病変」の多くは、生活習慣改善指導の重要性が医療介入よりも大きい。
  1. 労作時の心筋虚血による胸痛に対してはニトログリセリンの舌下服用が有効な場合が多い。
  1. 労作性狭心症は、心筋酸素需要の増加時に症候が発現する。心筋酸素需要を規定する因子には、血圧、心拍数、心筋収縮性などがある。血圧、脈拍、心筋収縮性を低下させ、労作性狭心症の発症を予防する手段としてβ遮断薬、Ca拮抗薬、硝酸薬などがある。
  1. 内科的治療が奏効しない場合には、冠動脈バイパス手術、カテーテルを用いた血管内治療などの適応となる。冠動脈バイパス手術は、左主幹部病変、三枝病変などで生命予後の改善を示すエビデンスがある。カテーテル治療により労作時の胸痛は軽減できるが、長期予後の改善を示す明確なエビデンスがない[1]
  1. 欧米諸国では冠動脈疾患の発症率、有病率が高い。日本では冠動脈疾患と脳血管疾患の比重が同程度である[2]
  1. Framingham研究から、高血圧(本態性高血圧症)、高コレステロール血症、糖尿病、喫煙と冠動脈疾患発症の強い関連が示されている。慢性期冠動脈疾患では、リスク因子の管理がきわめて重要である。
 
  1. 慢性期冠動脈疾患は全身の動脈硬化、血栓性病態の亢進した非可逆的病態であり、医療介入による予後改善効果は限られている。動脈硬化性変化が出現する前のリスク因子の段階における介入が重要である(推奨度1)。
  1. 慢性期冠動脈疾患の症例ではさまざまな医療介入を行っても、年間4%程度の症例が心血管死亡/心筋梗塞/脳卒中などの動脈硬化血栓性イベントを発症する。
  1. 世界44カ国から6万8,000例以上が登録されたREACH registryでは、冠動脈、脳血管、末梢血管に動脈硬化性病変を認めた症例は年間4%程度、認めなかった症例では1.5%程度が心血管死亡、心筋梗塞、脳卒中を発症した。
  1. 慢性期冠動脈疾患は治ることのない疾患である。長期間にわたる管理が必要である。
  1. 「冠動脈疾患」であっても脳血管、末梢血管にも病変が合併している可能性を考えること。
  1. 追記:日本人約5,000例を含む大規模前向きコホート研究である[3]
 
  1. 欧米データを日本人には直接適用することは難しい。
  1. 日本人の冠動脈疾患慢性期の症例の年間心筋梗塞発症再発リスクは、安定している症例では0.4%程度に過ぎない。また、日本人の慢性期冠動脈疾患の症例では、心筋梗塞リスクよりも脳梗塞リスクが高い。
  1. 多くの臨床エビデンスは欧米から発信され、日本人の症例が含まれていない。日本人に対して欧米人のエビデンスがどの程度適応可能かに関しても十分な情報がなかった。安定した慢性期冠動脈疾患の日本人症例のイベントリスクはきわめて低い。欧米データを日本人には直接適用できないと考えざるを得ない。
  1. 追記:日本国内から8,000例を超える心筋梗塞、脳梗塞、心房細動の症例を登録した本格的前向きコホート研究であり、信頼性が高い。
 
慢性期冠動脈疾患の心血管イベント発症リスク

日本人では、慢性期冠動脈疾患でも①脳卒中、②がん、など冠動脈以外の疾患に対する配慮が必要である。

出典

img1:  One-year cardiovascular event rates in Japanese outpatients with myocardial infarction, stroke, and atrial fibrillation. -Results From the Japan Thrombosis Registry for Atrial Fibrillation, Coronary, or Cerebrovascular Events (J-TRACE).-.
 
 Circ J. 2011;75(11):2598-604. Epub 2011 ・・・
問診・診察のポイント  
  1. 「胸痛」発症状況の丁寧な問診がきわめて重要。「痛み」よりは「違和感」、「圧迫感」などと表現されることが多い。

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文献 

著者: A B Makar, K E McMartin, M Palese, T R Tephly
雑誌名: Biochem Med. 1975 Jun;13(2):117-26. doi: 10.1016/0006-2944(75)90147-7.
Abstract/Text
PMID 1  Biochem Med. 1975 Jun;13(2):117-26. doi: 10.1016/0006-2・・・
著者: S Goto, Y Ikeda, J C N Chan, P W F Wilson, T Cheng Yeo, C S Liau, M T Abola, G Salette, P G Steg, D L Bhatt
雑誌名: Heart Asia. 2011;3(1):93-8. doi: 10.1136/ha.2010.002691. Epub 2011 Jan 1.
Abstract/Text OBJECTIVE: To clarify the differences in the baseline characteristics, prevalence and incidence of atherothrombosis in patients recruited from Asia versus non-Asian regions.
DESIGN: International Prospective Cohort Study.
SETTING: Region focused substudy.
PATIENTS: The Reduction of Atherothrombosis for Continued Health (REACH) Registry recruited 68 236 stable outpatients with established atherothrombosis or ≥3 atherothrombotic risk factors from 44 countries.
INTERVENTIONS: No intervention.
MAIN OUTCOME MEASURES: Risk factors, use of medications, vascular disease bed location, and 1-year cardiovascular (CV) outcomes (CV death, myocardial infarction, stroke).
RESULTS: The percentages of patients recruited with CVD (Cerebrovascular Disease) were higher in Asia (41.0%) than in non-Asian regions (25.1%) (p<0.0001). The prevalence of diabetes mellitus was higher in Asia (46.6%) than in non-Asian regions (43.3%) (p<0.0001) despite the former having a lower body mass index (BMI) (24.4±3.9 vs 28.8±5.6) (p<0.0001). The combined endpoint of CV death/myocardial infarction/stroke of patients recruited from non-Asian regions of 4.38% (95% CI 4.20 to 4.56) is equivalent to those from the Asian region excluding Japan of 4.65% (95% CI 4.04 to 5.25), but that is significantly lower in patients recruited from Japan of 3.40% (95% CI 2.76 to 4.04, p<0.05).
CONCLUSIONS: There is a higher prevalence of CVD and higher prevalence of diabetus mellitus with lower body mass index in patients recruited from the Asian region as compared those recruited from non-Asian regions. The CV event rate in patients recruited from non-Asian regions is equivalent to that of patients recruited from the Asian region excluding Japan, but significantly lower in patients recruited from Japan.

PMID 27326003  Heart Asia. 2011;3(1):93-8. doi: 10.1136/ha.2010.002691・・・
著者: Ph Gabriel Steg, Deepak L Bhatt, Peter W F Wilson, Ralph D'Agostino, E Magnus Ohman, Joachim Röther, Chiau-Suong Liau, Alan T Hirsch, Jean-Louis Mas, Yasuo Ikeda, Michael J Pencina, Shinya Goto, REACH Registry Investigators
雑誌名: JAMA. 2007 Mar 21;297(11):1197-206. doi: 10.1001/jama.297.11.1197.
Abstract/Text CONTEXT: Few data document current cardiovascular (CV) event rates in stable patients with atherothrombosis in a community setting. Differential event rates for patients with documented coronary artery disease (CAD), cerebrovascular disease (CVD), or peripheral arterial disease (PAD) or those at risk of these diseases have not been previously evaluated in a single international cohort.
OBJECTIVE: To establish contemporary, international, 1-year CV event rates in outpatients with established arterial disease or with multiple risk factors for atherothrombosis.
DESIGN, SETTING, AND PARTICIPANTS: The Reduction of Atherothrombosis for Continued Health (REACH) Registry is an international, prospective cohort of 68 236 patients with either established atherosclerotic arterial disease (CAD, PAD, CVD; n = 55 814) or at least 3 risk factors for atherothrombosis (n = 12 422), who were enrolled from 5587 physician practices in 44 countries in 2003-2004.
MAIN OUTCOME MEASURES: Rates of CV death, myocardial infarction (MI), and stroke.
RESULTS: As of July 2006, 1-year outcomes were available for 95.22% (n = 64 977) of participants. Cardiovascular death, MI, or stroke rates were 4.24% overall: 4.69% for those with established atherosclerotic arterial disease vs 2.15% for patients with multiple risk factors only. Among patients with established disease, CV death, MI, or stroke rates were 4.52% for patients with CAD, 6.47% for patients with CVD, and 5.35% for patients with PAD. The incidences of the end point of CV death, MI, or stroke or of hospitalization for atherothrombotic event(s) were 15.20% for CAD, 14.53% for CVD, and 21.14% for PAD patients with established disease. These event rates increased with the number of symptomatic arterial disease locations, ranging from 5.31% for patients with risk factors only to 12.58% for patients with 1, 21.14% for patients with 2, and 26.27% for patients with 3 symptomatic arterial disease locations (P<.001 for trend).
CONCLUSIONS: In this large, contemporary, international study, outpatients with established atherosclerotic arterial disease, or at risk of atherothrombosis, experienced relatively high annual CV event rates. Multiple disease locations increased the 1-year risk of CV events.

PMID 17374814  JAMA. 2007 Mar 21;297(11):1197-206. doi: 10.1001/jama.2・・・
著者: Seung-Jung Park, Young-Hak Kim, Duk-Woo Park, Sung-Cheol Yun, Jung-Min Ahn, Hae Geun Song, Jong-Young Lee, Won-Jang Kim, Soo-Jin Kang, Seung-Whan Lee, Cheol Whan Lee, Seong-Wook Park, Cheol-Hyun Chung, Jae-Won Lee, Do-Sun Lim, Seung-Woon Rha, Sang-Gon Lee, Hyeon-Cheol Gwon, Hyo-Soo Kim, In-Ho Chae, Yangsoo Jang, Myung-Ho Jeong, Seung-Jea Tahk, Ki Bae Seung
雑誌名: N Engl J Med. 2011 May 5;364(18):1718-27. doi: 10.1056/NEJMoa1100452. Epub 2011 Apr 4.
Abstract/Text BACKGROUND: Percutaneous coronary intervention (PCI) is increasingly used to treat unprotected left main coronary artery stenosis, although coronary-artery bypass grafting (CABG) has been considered to be the treatment of choice.
METHODS: We randomly assigned patients with unprotected left main coronary artery stenosis to undergo CABG (300 patients) or PCI with sirolimus-eluting stents (300 patients). Using a wide margin for noninferiority, we compared the groups with respect to the primary composite end point of major adverse cardiac or cerebrovascular events (death from any cause, myocardial infarction, stroke, or ischemia-driven target-vessel revascularization) at 1 year. Event rates at 2 years were also compared between the two groups.
RESULTS: The primary end point occurred in 26 patients assigned to PCI as compared with 20 patients assigned to CABG (cumulative event rate, 8.7% vs. 6.7%; absolute risk difference, 2.0 percentage points; 95% confidence interval [CI], -1.6 to 5.6; P=0.01 for noninferiority). By 2 years, the primary end point had occurred in 36 patients in the PCI group as compared with 24 in the CABG group (cumulative event rate, 12.2% vs. 8.1%; hazard ratio with PCI, 1.50; 95% CI, 0.90 to 2.52; P=0.12). The composite rate of death, myocardial infarction, or stroke at 2 years occurred in 13 and 14 patients in the two groups, respectively (cumulative event rate, 4.4% and 4.7%, respectively; hazard ratio, 0.92; 95% CI, 0.43 to 1.96; P=0.83). Ischemia-driven target-vessel revascularization occurred in 26 patients in the PCI group as compared with 12 patients in the CABG group (cumulative event rate, 9.0% vs. 4.2%; hazard ratio, 2.18; 95% CI, 1.10 to 4.32; P=0.02).
CONCLUSIONS: In this randomized trial involving patients with unprotected left main coronary artery stenosis, PCI with sirolimus-eluting stents was shown to be noninferior to CABG with respect to major adverse cardiac or cerebrovascular events. However, the noninferiority margin was wide, and the results cannot be considered clinically directive. (Funded by the Cardiovascular Research Foundation, Seoul, Korea, and others; PRECOMBAT ClinicalTrials.gov number, NCT00422968.).

PMID 21463149  N Engl J Med. 2011 May 5;364(18):1718-27. doi: 10.1056/・・・
著者: Deepak L Bhatt, P Gabriel Steg, E Magnus Ohman, Alan T Hirsch, Yasuo Ikeda, Jean-Louis Mas, Shinya Goto, Chiau-Suong Liau, Alain J Richard, Joachim Röther, Peter W F Wilson, REACH Registry Investigators
雑誌名: JAMA. 2006 Jan 11;295(2):180-9. doi: 10.1001/jama.295.2.180.
Abstract/Text CONTEXT: Atherothrombosis is the leading cause of cardiovascular morbidity and mortality around the globe. To date, no single international database has characterized the atherosclerosis risk factor profile or treatment intensity of individuals with atherothrombosis.
OBJECTIVE: To determine whether atherosclerosis risk factor prevalence and treatment would demonstrate comparable patterns in many countries around the world.
DESIGN, SETTING, AND PARTICIPANTS: The Reduction of Atherothrombosis for Continued Health (REACH) Registry collected data on atherosclerosis risk factors and treatment. A total of 67,888 patients aged 45 years or older from 5473 physician practices in 44 countries had either established arterial disease (coronary artery disease [CAD], n = 40,258; cerebrovascular disease, n = 18,843; peripheral arterial disease, n = 8273) or 3 or more risk factors for atherothrombosis (n = 12,389) between 2003 and 2004.
MAIN OUTCOME MEASURES: Baseline prevalence of atherosclerosis risk factors, medication use, and degree of risk factor control.
RESULTS: Atherothrombotic patients throughout the world had similar risk factor profiles: a high proportion with hypertension (81.8%), hypercholesterolemia (72.4%), and diabetes (44.3%). The prevalence of overweight (39.8%), obesity (26.6%), and morbid obesity (3.6%) were similar in most geographic locales, but was highest in North America (overweight: 37.1%, obese: 36.5%, and morbidly obese: 5.8%; P<.001 vs other regions). Patients were generally undertreated with statins (69.4% overall; range: 56.4% for cerebrovascular disease to 76.2% for CAD), antiplatelet agents (78.6% overall; range: 53.9% for > or =3 risk factors to 85.6% for CAD), and other evidence-based risk reduction therapies. Current tobacco use in patients with established vascular disease was substantial (14.4%). Undertreated hypertension (50.0% with elevated blood pressure at baseline), undiagnosed hyperglycemia (4.9%), and impaired fasting glucose (36.5% in those not known to be diabetic) were common. Among those with symptomatic atherothrombosis, 15.9% had symptomatic polyvascular disease.
CONCLUSION: This large, international, contemporary database shows that classic cardiovascular risk factors are consistent and common but are largely undertreated and undercontrolled in many regions of the world.

PMID 16403930  JAMA. 2006 Jan 11;295(2):180-9. doi: 10.1001/jama.295.2・・・
著者: Deepak L Bhatt, Kim A Eagle, E Magnus Ohman, Alan T Hirsch, Shinya Goto, Elizabeth M Mahoney, Peter W F Wilson, Mark J Alberts, Ralph D'Agostino, Chiau-Suong Liau, Jean-Louis Mas, Joachim Röther, Sidney C Smith, Geneviève Salette, Charles F Contant, Joseph M Massaro, Ph Gabriel Steg, REACH Registry Investigators
雑誌名: JAMA. 2010 Sep 22;304(12):1350-7. doi: 10.1001/jama.2010.1322. Epub 2010 Aug 30.
Abstract/Text CONTEXT: Clinicians and trialists have difficulty with identifying which patients are highest risk for cardiovascular events. Prior ischemic events, polyvascular disease, and diabetes mellitus have all been identified as predictors of ischemic events, but their comparative contributions to future risk remain unclear.
OBJECTIVE: To categorize the risk of cardiovascular events in stable outpatients with various initial manifestations of atherothrombosis using simple clinical descriptors.
DESIGN, SETTING, AND PATIENTS: Outpatients with coronary artery disease, cerebrovascular disease, or peripheral arterial disease or with multiple risk factors for atherothrombosis were enrolled in the global Reduction of Atherothrombosis for Continued Health (REACH) Registry and were followed up for as long as 4 years. Patients from 3647 centers in 29 countries were enrolled between 2003 and 2004 and followed up until 2008. Final database lock was in April 2009.
MAIN OUTCOME MEASURES: Rates of cardiovascular death, myocardial infarction, and stroke.
RESULTS: A total of 45,227 patients with baseline data were included in this 4-year analysis. During the follow-up period, a total of 5481 patients experienced at least 1 event, including 2315 with cardiovascular death, 1228 with myocardial infarction, 1898 with stroke, and 40 with both a myocardial infarction and stroke on the same day. Among patients with atherothrombosis, those with a prior history of ischemic events at baseline (n = 21,890) had the highest rate of subsequent ischemic events (18.3%; 95% confidence interval [CI], 17.4%-19.1%); patients with stable coronary, cerebrovascular, or peripheral artery disease (n = 15,264) had a lower risk (12.2%; 95% CI, 11.4%-12.9%); and patients without established atherothrombosis but with risk factors only (n = 8073) had the lowest risk (9.1%; 95% CI, 8.3%-9.9%) (P < .001 for all comparisons). In addition, in multivariable modeling, the presence of diabetes (hazard ratio [HR], 1.44; 95% CI, 1.36-1.53; P < .001), an ischemic event in the previous year (HR, 1.71; 95% CI, 1.57-1.85; P < .001), and polyvascular disease (HR, 1.99; 95% CI, 1.78-2.24; P < .001) each were associated with a significantly higher risk of the primary end point.
CONCLUSION: Clinical descriptors can assist clinicians in identifying high-risk patients within the broad range of risk for outpatients with atherothrombosis.

PMID 20805624  JAMA. 2010 Sep 22;304(12):1350-7. doi: 10.1001/jama.201・・・
著者: Antithrombotic Trialists' (ATT) Collaboration, Colin Baigent, Lisa Blackwell, Rory Collins, Jonathan Emberson, Jon Godwin, Richard Peto, Julie Buring, Charles Hennekens, Patricia Kearney, Tom Meade, Carlo Patrono, Maria Carla Roncaglioni, Alberto Zanchetti
雑誌名: Lancet. 2009 May 30;373(9678):1849-60. doi: 10.1016/S0140-6736(09)60503-1.
Abstract/Text BACKGROUND: Low-dose aspirin is of definite and substantial net benefit for many people who already have occlusive vascular disease. We have assessed the benefits and risks in primary prevention.
METHODS: We undertook meta-analyses of serious vascular events (myocardial infarction, stroke, or vascular death) and major bleeds in six primary prevention trials (95,000 individuals at low average risk, 660,000 person-years, 3554 serious vascular events) and 16 secondary prevention trials (17,000 individuals at high average risk, 43,000 person-years, 3306 serious vascular events) that compared long-term aspirin versus control. We report intention-to-treat analyses of first events during the scheduled treatment period.
FINDINGS: In the primary prevention trials, aspirin allocation yielded a 12% proportional reduction in serious vascular events (0.51% aspirin vs 0.57% control per year, p=0.0001), due mainly to a reduction of about a fifth in non-fatal myocardial infarction (0.18%vs 0.23% per year, p<0.0001). The net effect on stroke was not significant (0.20%vs 0.21% per year, p=0.4: haemorrhagic stroke 0.04%vs 0.03%, p=0.05; other stroke 0.16%vs 0.18% per year, p=0.08). Vascular mortality did not differ significantly (0.19%vs 0.19% per year, p=0.7). Aspirin allocation increased major gastrointestinal and extracranial bleeds (0.10%vs 0.07% per year, p<0.0001), and the main risk factors for coronary disease were also risk factors for bleeding. In the secondary prevention trials, aspirin allocation yielded a greater absolute reduction in serious vascular events (6.7%vs 8.2% per year, p<0.0001), with a non-significant increase in haemorrhagic stroke but reductions of about a fifth in total stroke (2.08%vs 2.54% per year, p=0.002) and in coronary events (4.3%vs 5.3% per year, p<0.0001). In both primary and secondary prevention trials, the proportional reductions in the aggregate of all serious vascular events seemed similar for men and women.
INTERPRETATION: In primary prevention without previous disease, aspirin is of uncertain net value as the reduction in occlusive events needs to be weighed against any increase in major bleeds. Further trials are in progress.
FUNDING: UK Medical Research Council, British Heart Foundation, Cancer Research UK, and the European Community Biomed Programme.

PMID 19482214  Lancet. 2009 May 30;373(9678):1849-60. doi: 10.1016/S01・・・
著者: Luis A García Rodríguez, Lucía Cea-Soriano, Elisa Martín-Merino, Saga Johansson
雑誌名: BMJ. 2011 Jul 19;343:d4094. Epub 2011 Jul 19.
Abstract/Text OBJECTIVES: To evaluate the risk of myocardial infarction and death from coronary heart disease after discontinuation of low dose aspirin in primary care patients with a history of cardiovascular events.
DESIGN: Nested case-control study.
SETTING: The Health Improvement Network (THIN) database in the United Kingdom.
PARTICIPANTS: Individuals aged 50-84 with a first prescription for aspirin (75-300 mg/day) for secondary prevention of cardiovascular outcomes in 2000-7 (n=39,513).
MAIN OUTCOME MEASURES: Individuals were followed up for a mean of 3.2 years to identify cases of non-fatal myocardial infarction or death from coronary heart disease. A nested case-control analysis assessed the risk of these events in those who had stopped taking low dose aspirin compared with those who had continued treatment.
RESULTS: There were 876 non-fatal myocardial infarctions and 346 deaths from coronary heart disease. Compared with current users, people who had recently stopped taking aspirin had a significantly increased risk of non-fatal myocardial infarction or death from coronary heart disease combined (rate ratio 1.43, 95% confidence interval 1.12 to 1.84) and non-fatal myocardial infarction alone (1.63, 1.23 to 2.14). There was no significant association between recently stopping low dose aspirin and the risk of death from coronary heart disease (1.07, 0.67 to 1.69). For every 1000 patients, over a period of one year there were about four more cases of non-fatal myocardial infarction among patients who discontinued treatment with low dose aspirin (recent discontinuers) compared with patients who continued treatment.
CONCLUSIONS: Individuals with a history of cardiovascular events who stop taking low dose aspirin are at increased risk of non-fatal myocardial infarction compared with those who continue treatment.

PMID 21771831  BMJ. 2011 Jul 19;343:d4094. Epub 2011 Jul 19.

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