avkАрхивъ внутренней медициныThe Russian Archives of Internal Medicine2226-67042411-6564“SINAPS” LLC10.20514/2226-6704-2016-6-6-56-64avk-601Research ArticleРАЗБОР КЛИНИЧЕСКИХ СЛУЧАЕВANALYSIS OF CLINICAL CASESЯТРОГЕННЫЕ СОБЫТИЯ ОРАЛЬНОЙ АНТИТРОМБОТИЧЕСКОЙ ТЕРАПИИ. МЕЖДУ СЦИЛЛОЙ И ХАРИБДОЙIATROGENIC EVENTS OF ORAL ANTITHROMBOTIC THERAPY. BETWEEN SCYLLA AND CHARYBDISДворецкийЛ. И.DvoretskyL. I.dvoretski@mail.ruРезванВ. В.RezvanV. V.dvoretski@mail.ruМагнитскийА. В.MagnitskyA. V.dvoretski@mail.ruГБОУ ВПО 1 МГМУ им. И.М. Сеченова, кафедра госпитальной терапии № 2, Москва, Россия ГБУЗ Госпиталь ветеранов войн № 3 ДЗМ, Москва, РоссияРоссияFirst Moscow State Medical University na I.M. Sechenov, Department of Hospital Therapy № 2 Medical Faculty, Moscow, Russia Hospital for War Veterans № 3 city health department, Moscow, RussiaRussian Federation201630122016665664Copyright © Дворецкий Л.И., Резван В.В., Магнитский А.В., 20162016Дворецкий Л.И., Резван В.В., Магнитский А.В.Dvoretsky L.I., Rezvan V.V., Magnitsky A.V.Данная работа распространяется под лицензией Creative Commons Attribution 4.0.This work is licensed under a Creative Commons Attribution 4.0 License.https://www.medarhive.ru/jour/article/view/601

Тромботические осложнения являются одной из распространенных проблем в клинической практике. Наиболее актуальными являются тромбозы коронарных сосудов с развитием инфаркта миокарда, ишемические инфаркты мозга у больных фибрилляцией предсердий, венозные тромбозы, осложненные тромбоэмболией легочной артерии. Использование оральных антитромботических препаратов значительно снизило частоту фатальных тромботических осложнений. Однако использование этой группы препаратов ассоциируется с повышенным рис ком кровотечений, которые нередко оказываются фатальными для больного. В статье изложена современная тактики лечения пациентов, получающих различные оральные антитромботические препараты, приведен типичный клинический пример развития осложнений. 

Thrombotic complications are a common problem in clinical practice. The most important are coronary thrombosis with myocardial infarction, ischemic cerebral infarcts in patients with atrial fibrillation, venous thrombosis complicated by pulmonary embolism. The use of oral antiplatelet therapy significantly reduced the incidence of fatal thrombotic complications. However, use of this group of drugs is associated with an increased risk of bleeding, which often turn out to be fatal for the patient. In the article presented the modern tactics of treatment of patients receiving a variety of oral antithrombotic agents, described a typical example of clinical complications.

тромбозоральные антитромботические препаратыгеморрагические осложненияthrombosisoral antithrombotic drugshemorrhagic complicationsReferencesCleland J.G.F. , Cowburn P.J., Falk R.H. Should all patients with atrial fibrillation receive warfarin? Evidence from randomized clinical trials. Eur. Heart. J. 1996; 17: 674–81Cleland J.G.F. , Cowburn P.J., Falk R.H. Should all patients with atrial fibrillation receive warfarin? Evidence from randomized clinical trials. Eur. Heart. J. 1996; 17: 674–81Hylek E.M., Skates S.J. Sheehan M.A., Singer D.E. An analysis of the lowest effective intensity of prophylactic anticoagulation for patients with nonrheumatic atrial fibrillation. N. Engl. J. Med. 1996; 335 (8): 540-546Hylek E.M., Skates S.J. Sheehan M.A., Singer D.E. An analysis of the lowest effective intensity of prophylactic anticoagulation for patients with nonrheumatic atrial fibrillation. N. Engl. J. Med. 1996; 335 (8): 540-546Бокарев И.Н., Козлова Т.Н. Применение варфарина в профилактике и лечении артериальных и венозных тромбозом. Ярославль. 2012; 30-47.Бокарев И.Н., Козлова Т.Н. Применение варфарина в профилактике и лечении артериальных и венозных тромбозом. Ярославль. 2012; 30-47.Bokarev I.N., Kozlova T.N. The use of warfarin in the prevention and treatment of arterial and venous thrombosis. Yaroslavl. 2012; 30-47 [in Russian].Bokarev I.N., Kozlova T.N. The use of warfarin in the prevention and treatment of arterial and venous thrombosis. Yaroslavl. 2012; 30-47 [in Russian].Гиляров М.Ю., Константинова Е.В. Фибрилляция предсердий как фактор риска ишемического инсульта. Сonsilium Medicum. 2015; 17(9): 16-19.Гиляров М.Ю., Константинова Е.В. Фибрилляция предсердий как фактор риска ишемического инсульта. Сonsilium Medicum. 2015; 17(9): 16-19.Gilyarov M.Yu., Konstantinova E.V. Atrial fibrillation as a risk factor for ischemic stroke. Sonsilium Medicum. 2015; 17(9): 16-19 [in Russian].Gilyarov M.Yu., Konstantinova E.V. Atrial fibrillation as a risk factor for ischemic stroke. Sonsilium Medicum. 2015; 17(9): 16-19 [in Russian].Fihn S.D., McDoneli., Martin D. Et al. Risk factors for complication of chronic anticoagulation, multi-center study; Warfarin Optimized Outpatient Follow-up Study Group. Ann. Intern. Med 1993; 118: 511-520.Fihn S.D., McDoneli., Martin D. Et al. Risk factors for complication of chronic anticoagulation, multi-center study; Warfarin Optimized Outpatient Follow-up Study Group. Ann. Intern. Med 1993; 118: 511-520.Fang M.C., Go A.S., Chang Y. et al. Death and disability from warfarin- associated intracranial and extracranial hemorrhages. Am. J. Med. 2007; 120: 700-705.Fang M.C., Go A.S., Chang Y. et al. Death and disability from warfarin- associated intracranial and extracranial hemorrhages. Am. J. Med. 2007; 120: 700-705.Gomes T., Mamdani M.M., Holbrook A.M. et al. Rates hemorrhage during warfarin therapy for atrial fibrillation. CMAJ. 2013; 185: 121-127.Gomes T., Mamdani M.M., Holbrook A.M. et al. Rates hemorrhage during warfarin therapy for atrial fibrillation. CMAJ. 2013; 185: 121-127.Poli D., Antonucci E., Grifoni E., et al. Bleeding risk during oral anticoagulation in atrial fibrillation patients older than 80 years. J. Am. Coll. Cardiol. 2009; 54: 999-1002.Poli D., Antonucci E., Grifoni E., et al. Bleeding risk during oral anticoagulation in atrial fibrillation patients older than 80 years. J. Am. Coll. Cardiol. 2009; 54: 999-1002.Hughes M., Lip G.Y., Guideline Development Group for the NICE national clinical guideline for management of atrial fibrillation in primary and secondary care. Risk factors for anticoagulation-related bleeding complications in patients with atrial fibrillation: a systematic review. QJM. 2007; 100: 599-607.Hughes M., Lip G.Y., Guideline Development Group for the NICE national clinical guideline for management of atrial fibrillation in primary and secondary care. Risk factors for anticoagulation-related bleeding complications in patients with atrial fibrillation: a systematic review. QJM. 2007; 100: 599-607.Serebruany V.I., Atar D. Assesment of bleeding events in clinical trials- proposal of new classification. Am. J. Cardiol. 2007; 99: 288.Serebruany V.I., Atar D. Assesment of bleeding events in clinical trials- proposal of new classification. Am. J. Cardiol. 2007; 99: 288.Leis W., Mean M., Limacher A. et al. Polypharmacy is associated with an increased risk of bleeding in elderly patients with venous thrombo- embolism. J. Gen. Intern. Med. 2015; 30(1): 17-24.Leis W., Mean M., Limacher A. et al. Polypharmacy is associated with an increased risk of bleeding in elderly patients with venous thrombo- embolism. J. Gen. Intern. Med. 2015; 30(1): 17-24.Connolly S.J., Ezekowitz M.D., Yusuf S. et al. Dabigatran versus warfarin in patients with atrial fibrillation. N. Engl. J. Med. 2009; 361: 1139-1151.Connolly S.J., Ezekowitz M.D., Yusuf S. et al. Dabigatran versus warfarin in patients with atrial fibrillation. N. Engl. J. Med. 2009; 361: 1139-1151.Patel M.R., Mahaffey K.W., Garg J. et al. Rivaroxaban versus warfarin in nonvalvular atrial fibrillation. N. Engl. J. Med. 2011; 365: 883-891.Patel M.R., Mahaffey K.W., Garg J. et al. Rivaroxaban versus warfarin in nonvalvular atrial fibrillation. N. Engl. J. Med. 2011; 365: 883-891.Granger C.B., Alexander J.H., McMurray J.J. et al. Apixaban versus warfarin in patients with atrial fibrillation. N. Engl. J. Med. 2011; 365: 981-992.Granger C.B., Alexander J.H., McMurray J.J. et al. Apixaban versus warfarin in patients with atrial fibrillation. N. Engl. J. Med. 2011; 365: 981-992.Ezekowitz M.D., Wallentin L., Connolly S.J. et al. Dabigatran and warfarin in vitamin K antagonist-naive and -experienced cohorts with atrial fibrillation. Circulation. 2010; 122: 2246-2253.Ezekowitz M.D., Wallentin L., Connolly S.J. et al. Dabigatran and warfarin in vitamin K antagonist-naive and -experienced cohorts with atrial fibrillation. Circulation. 2010; 122: 2246-2253.Eikelboom J.W., Wallentin L., Connolly S.J. et al. Risk of bleeding with 2 doses of dabigatran compared with warfarin in older and younger patients with atrial fibrillation: an analysis of the randomized evalua- tion of long-term anticoagulant therapy (RE-LY) trial. Circulation. 2011; 123: 2363-2372.Eikelboom J.W., Wallentin L., Connolly S.J. et al. Risk of bleeding with 2 doses of dabigatran compared with warfarin in older and younger patients with atrial fibrillation: an analysis of the randomized evalua- tion of long-term anticoagulant therapy (RE-LY) trial. Circulation. 2011; 123: 2363-2372.Dy E.A., Shiltz D.L. Hemopericardium and cardiac tamponade associated with dabigatran use. Ann. Pharmacother. 2012; 46(7-8): e18.Dy E.A., Shiltz D.L. Hemopericardium and cardiac tamponade associated with dabigatran use. Ann. Pharmacother. 2012; 46(7-8): e18.http://www.fda.gov/Safety/MedWatch/SafetyInformation/ SafetyAlertsforHuma MedicalProducts/ucm282820. htm?source=govdelivery (Accessed on November 02, 2012http://www.fda.gov/Safety/MedWatch/SafetyInformation/ SafetyAlertsforHuma MedicalProducts/ucm282820. htm?source=govdelivery (Accessed on November 02, 2012Southworth M.R., Reichman M.E., Unger E.F. Dabigatran and postmarketing reports of bleeding. N. Engl. J. Med. 2013; 368: 1272-1274.Southworth M.R., Reichman M.E., Unger E.F. Dabigatran and postmarketing reports of bleeding. N. Engl. J. Med. 2013; 368: 1272-1274.Larsen T.B., Rasmussen L.H., Skjøth F. et al. Efficacy and safety of dabigatran etexilate and warfarin in “real-world” patients with atrial fibrillation: a prospective nationwide cohort study. J. Am. Coll. Cardiol. 2013; 61: 2264-2273.Larsen T.B., Rasmussen L.H., Skjøth F. et al. Efficacy and safety of dabigatran etexilate and warfarin in “real-world” patients with atrial fibrillation: a prospective nationwide cohort study. J. Am. Coll. Cardiol. 2013; 61: 2264-2273.ACTIVE Writing Group of the ACTIVE Investigators, Connolly S., Pogue J. et al. Clopidogrel plus aspirin versus oral anticoagulation for atrial fibrillation in the Atrial fibrillation Clopidogrel Trial with Irbesartan for prevention of Vascular Events (ACTIVE W): a randomised controlled trial. Lancet. 2006; 367: 1903-1912.ACTIVE Writing Group of the ACTIVE Investigators, Connolly S., Pogue J. et al. Clopidogrel plus aspirin versus oral anticoagulation for atrial fibrillation in the Atrial fibrillation Clopidogrel Trial with Irbesartan for prevention of Vascular Events (ACTIVE W): a randomised controlled trial. Lancet. 2006; 367: 1903-1912.ACTIVE Investigators, Connolly S.J., Pogue J. et al. Effect of clopidogrel added to aspirin in patients with atrial fibrillation. N. Engl. J. Med. 2009; 360: 2066-2078ACTIVE Investigators, Connolly S.J., Pogue J. et al. Effect of clopidogrel added to aspirin in patients with atrial fibrillation. N. Engl. J. Med. 2009; 360: 2066-2078Sorensen R., Hansen M., Abildstrom S. et al. Risk of bleeding in patients with acute myocardial infarction treated with different combinations of aspirin, clopidogrel, and vitamin K antagonists in Denmark: a retrospective analysis of nationwide registry data. Lancet. 2009; 374: 1967-1974.Sorensen R., Hansen M., Abildstrom S. et al. Risk of bleeding in patients with acute myocardial infarction treated with different combinations of aspirin, clopidogrel, and vitamin K antagonists in Denmark: a retrospective analysis of nationwide registry data. Lancet. 2009; 374: 1967-1974.Rockall T.A., Logan R.F.A., Devlin H.B. et al. Risk assessment after up- per gastrointestinal haemorrhage. Gut. 1996; 38(3): 316-321Rockall T.A., Logan R.F.A., Devlin H.B. et al. Risk assessment after up- per gastrointestinal haemorrhage. Gut. 1996; 38(3): 316-321Gurbel P.A, Biden K.P., Hayes K.M., Tantry U.S. The relation of dosing to clopidogrel responsiveness and the incidence of high post-treatment platelet aggregation in patients undergoing coronary stenting. J. Am. Coll. Cardioll. 2005; 45: 1392-1396.Gurbel P.A, Biden K.P., Hayes K.M., Tantry U.S. The relation of dosing to clopidogrel responsiveness and the incidence of high post-treatment platelet aggregation in patients undergoing coronary stenting. J. Am. Coll. Cardioll. 2005; 45: 1392-1396.

The authors declare that there are no conflicts of interest present.