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首页> 外文期刊>The Internet Journal of Neurology >Can This Patient Take A Triptan?: Review Of The Cardiovascular Safety Of The Triptans And Recommendations For Patient Selection And Evaluation
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Can This Patient Take A Triptan?: Review Of The Cardiovascular Safety Of The Triptans And Recommendations For Patient Selection And Evaluation

机译：该患者可以服用曲普坦吗？：复查曲普坦的心血管安全性以及患者选择和评估的建议

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摘要

Background: Treatment guidelines issued in 2001 by the United States Headache Consortium emphasize the use of 5-HT1B/1D agonists (triptans) as preferred agents for abortive treatment of moderate to severe migraine. Despite this, triptans are used by only a minority of patients whose attacks are severe enough to require prescription medication, primarily because of persistent concern about their cardiovascular safety.Discussion: Serious triptan-related cardiac events have occurred, primarily in patients with known cardiac risk factors, but the efficacy and safety of triptans favor their use for the acute treatment of migraine in patients at low risk for cardiovascular disease. The use of simple, validated risk stratification systems such as the Framingham Risk Score, is one method of evaluating cardiovascular risk status in a clinical setting.Summary: Triptans are safe for the majority of patients with migraine, but clinical assessment of the underlying probability of cardiovascular disease is important prior to triptan prescription. Support: No support was received for preparation of this manuscript. Commercial ties: Both Dr. Loder and Dr. Biondi have been investigators in clinical trials of migraine medications, consulted for and/or received research grants or honoraria for speaking from the following manufacturers of migraine medications: AstraZeneca, GlaxoSmithKline, Merck, Pfizer, Elan and Ortho-McNeil. Background Migraine is a primary headache disorder that affects 17% of women and 6% of men in the United States. (1) It is an important cause of chronic pain, disability and work absenteeism among otherwise healthy adults, especially women during their reproductive years. (2) The World Health Organization considers that a day with severe migraine imposes disability comparable to that of a day with active psychosis, dementia or quadriplegia, and places migraine among the top 20 causes of disability worldwide. (3) Migraine is a problem that is encountered and treated in a wide variety of medical settings, including primary care and neurology. (4) Treatment guidelines issued in 2001 by the United States Headache Consortium emphasize the use of 5-HT1B/1D agonists (triptans) as preferred agents for abortive treatment of moderate to severe migraine. (5) Despite this recommendation, triptans are used by only 20% of migraineurs whose attacks are severe enough to require prescription medication. (6) Among the many reasons for this low use of “best practice” treatment for migraine, persistent concern about the cardiovascular safety of the triptans stands out as a frequently cited barrier. (7) Mild, transient “triptan sensations,” including chest pain that can resemble angina, occur in 3% to 8% of patients receiving a triptan in clinical practice. (8,9) It can be difficult to distinguish these noncardiac symptoms from chest pain induced by coronary artery constriction. (10) Furthermore, a small number of serious cardiac adverse effects, some fatal, have been associated with triptan use. Physicians have thus been understandably reluctant to prescribe triptans in the absence of reassuring long-term data about their cardiovascular safety. The manufacturers' package inserts for all available triptans state that the drugs are contraindicated in patients with confirmed or suspected coronary artery disease (CAD) and in patients with risk factors for coronary artery disease unless they have undergone a thorough cardiovascular evaluation providing “satisfactory clinical evidence that the patient is reasonably free of coronary artery and ischemic myocardial disease or other significant underlying cardiovascular disease.” (11,12,13,14,15,16,17) However, they do not elaborate on what that evaluation should be, and point out that “the sensitivity of cardiac diagnostic procedures to detect cardiovascular disease or predisposition to coronary artery vasospasm is modest, at best.” They recommend that patients with risk factors predictive of CAD who h
机译：背景：美国头痛协会于2001年发布的治疗指南强调使用5-HT1B / 1D激动剂（曲普坦）作为中度至重度偏头痛的流产治疗的首选药物。尽管如此，曲普坦类药物仅被少数发作严重而需要处方药的患者使用，主要是因为他们对心血管安全性的持续关注。讨论：与曲普坦类药物有关的严重心脏事件已经发生，主要发生在已知心脏风险的患者中的因素，但曲普坦的疗效和安全性有利于将其用于心血管疾病低风险患者的偏头痛的急性治疗。使用简单且经过验证的风险分层系统（例如Framingham风险评分）是评估临床环境中心血管疾病风险状况的一种方法。摘要：曲坦类药物对大多数偏头痛患者是安全的，但临床评估其潜在的风险曲坦处方之前，心血管疾病很重要。支持：没有人准备此手稿。商业关系：Loder博士和Biondi博士都是偏头痛药物临床试验的研究人员，并从以下偏头痛药物生产商的演讲中获得咨询和/或获得研究补助金或酬金：阿斯利康，葛兰素史克，默克，辉瑞，辉瑞和Ortho-McNeil。背景偏头痛是一种原发性头痛疾病，在美国影响到17％的女性和6％的男性。 （1）这是在其他方面健康的成年人，尤其是生育年龄的女性中引起慢性疼痛，残疾和缺勤的重要原因。 （2）世界卫生组织认为，严重偏头痛的一天所造成的残疾与活动性精神病，痴呆或四肢瘫痪的一天相当，并将偏头痛列为全球残疾的前二十大原因。 （3）偏头痛是在包括基层医疗和神经病学在内的多种医学环境中遇到和治疗的问题。 （4）美国头痛协会于2001年发布的治疗指南强调使用5-HT1B / 1D激动剂（曲普坦）作为中度至重度偏头痛的流产治疗的首选药物。 （5）尽管有此建议，但偏头痛发作的严重程度足以需要处方药的偏头痛患者中，只有20％使用曲坦类药物。 （6）在偏头痛偏低使用“最佳实践”治疗的众多原因中，对曲普坦类药物的心血管安全性的持续关注是经常被提及的障碍。 （7）在临床实践中，接受曲普坦治疗的患者中有3％至8％出现轻度，短暂的“曲普坦感觉”，包括类似心绞痛的胸痛。 （8,9）很难将这些非心脏症状与冠状动脉收缩引起的胸痛区分开来。 （10）此外，曲坦类药物的使用会导致少量严重的心脏不良反应，甚至是致命的。因此，在缺乏令人放心的关于心血管安全性的长期数据的情况下，医生一直不愿开出曲普坦。制造商针对所有可用曲普坦类药物的包装插页中指出，除非已经过全面的心血管评估以提供“令人满意的临床证据”，否则已确诊或怀疑冠心病（CAD）的患者和有冠心病危险因素的患者均禁用该药物。患者完全没有冠状动脉和缺血性心肌病或其他重要的潜在心血管疾病。” （11,12,13,14,15,16,17）但是，他们没有详细说明该评估应该是什么，并指出“心脏诊断程序对检测心血管疾病或易患冠状动脉血管痉挛的敏感性是谦虚，充其量。”他们建议患有可预测CAD危险因素的患者

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