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Нюансы антикоагулянтной терапии у пациентов с хронической болезнью почек и фибрилляцией предсердий

https://doi.org/10.18087/cardio.2018.10.10185

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Аннотация

Скорость клубочковой фильтрации (СКФ) снижается с возрастом после 50 лет. Число пациентов с фибрилляцией предсердий (ФП) и хронической болезнью почек (ХБП) ежегодно увеличивается. Риск развития ишемического инсульта и тромбоэмболических осложнений, как и риск кровотечений, значительно выше у пациентов с ФП при наличии у них сопутствующей дисфункции почек. Результаты четырех рандомизированных клинических исследований (РКИ) продемонстрировали преимущества новых прямых пероральных антикоагулянтов (ППОАК) по сравнению с варфарином, однако эти РКИ имели серьезные ограничения, обусловленные включением относительно низкой доли пациентов с выраженной ХБП. Исследование ROCKET-AF отличалось от других РКИ (RE-LY, ARISTOTLE) более высокими рисками у пациентов с ФП, оцененными по шкалам CHADS2 и HAS-BLED. Международное нормализованное отношение, находящееся вне терапевтического окна, ассоциировано с ухудшением функции почек у лиц с ФП, принимающих варфарин. У пациентов с клинически значимой дисфункцией почек необходимо уменьшение дозы ППОАК, так как все ППОАК в определенной мере выводятся почками. Пренебрежение рекомендациями в уменьшении дозы ППОАК у пациентов со сниженной функцией почек может привести к повышению риска кровотечений, и, наоборот, некорректное снижение дозы без четких показаний может снизить эффективность ППОАК в профилактике инсульта. В данной статье обсуждаются фармакологические характеристики ППОАК в зависимости от степени нарушения функции почек, важные нюансы при выборе антикоагулянтной терапии ППОАК у пациентов с сосуществующими ФП и ХБП.

Об авторах

Ж. Д. Кобалава
Федеральное государственное автономное бюджетное образовательное учреждение высшего профессионального образования «Российский университет дружбы народов»
Россия


А. А. Шаваров
Федеральное государственное автономное бюджетное образовательное учреждение высшего профессионального образования «Российский университет дружбы народов»
Россия


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Для цитирования:


Кобалава Ж.Д., Шаваров А.А. Нюансы антикоагулянтной терапии у пациентов с хронической болезнью почек и фибрилляцией предсердий. Кардиология. 2018;58(10):59-70. https://doi.org/10.18087/cardio.2018.10.10185

For citation:


Kobalava Z.D., Shavarov A.A. Nuances in Anticoagulation Treatment in Patients With Chronic Kidney Disease and Atrial Fibrillation. Kardiologiia. 2018;58(10):59-70. (In Russ.) https://doi.org/10.18087/cardio.2018.10.10185

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