TEG在评价冠心病患者PCI术后抗血小板治疗效果及监测缺血、出血事件发生中的作用
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摘要
目的应用血栓弹力图(TEG)监测冠心病患者经皮冠状动脉介入(PCI)术后应用抗血小板药物的效果,分析其与PCI术后患者缺血和出血事件的关系。方法收集2017年7月～2018年5月广东省惠州市第一人民医院(以下简称"我院")诊断为冠心病并行PCI治疗的患者300例,均予阿司匹林和氯吡格雷进行双联抗血小板治疗,以血小板花生四烯酸(AA)途径血小板聚集抑制率≥50%定义阿司匹林起效,二磷酸腺苷(ADP)途径血小板聚集抑制率≥30%定义氯吡格雷起效。根据TEG AA/ADP抑制率结果分为阿司匹林+氯吡格雷起效组(AA及ADP抑制率均达标)200例,阿司匹林未起效组30例,氯吡格雷未起效组50例,阿司匹林+氯吡格雷未起效组20例。比较四组的血小板抑制率及随访半年内的缺血事件总发生率。根据TEG中二磷酸腺苷诱导最大血块强度(MA-ADP)结果分为MA-ADP<31 mm组、31 mm≤MA-ADP≤47 mm组、MA-ADP>47 mm组,比较三组的血小板抑制率、出血事件总发生率。结果四组患者的血小板抑制率、缺血事件总发生率比较,差异有统计学意义(P <0.05)。阿司匹林+氯吡格雷起效组血小板抑制率最高,显著高于其他各组(P <0.05)。阿司匹林+氯吡格雷未起效组的缺血事件总发生率达35.00%,显著高于其他各组(P <0.05)。将纳入的300例患者按照TEG MA-ADP结果分为MA-ADP<31 mm组、31 mm≤MA-ADP≤47 mm组、MA-ADP>47 mm组,三组患者血小板抑制率、出血事件总发生率比较,差异有统计学意义(P <0.05)。其中MA-ADP>47 mm组的血小板抑制率显著低于其他两组(P <0.05)。其中MA-ADP>47 mm组的出血事件总发生率仅5%,显著低于其他两组(P <0.05)。结论对于PCI术后接受抗血小板治疗的患者,应用TEG进行监测,可指导抗血小板治疗方案的调整,确保血小板聚集活性的抑制效果,从而减少心血管不良事件的发生。
Objective To monitor the effect of antiplatelet drugs after percutaneous coronary intervention(PCI) in patients with coronary heart disease by thromboelastography(TEG), and to analyze its relationship with ischemic and hemorrhagic events after PCI. Methods A total of 300 patients with coronary heart disease diagnosed by the First People′s Hospital of Huizhou City of Guangdong Province( "our hospital" for short) and treated with PCI were collected from July 2017 to May 2018. All patients were treated with aspirin and clopidogrel for antiplatelet therapy. The arachidonic acid(AA) pathway platelet aggregation inhibition rate ≥ 50% defines Aspirin onset; the adenosine diphosphate(ADP) pathway platelet aggregation inhibition rate ≥ 30% defines Clopidogrel onset. According to the results of TEG AA/ADP inhibition rate, 200 cases were divided into Aspirin + Clopidogrel effective group(AA and ADP inhibition rates were up to standard), 30 cases in Aspirin ineffective group, 50 cases in Clopidogrel ineffective group and 20 cases in Aspirin + Clopidogrel ineffective group. The platelet inhibition rate and the total incidence of ischemic events within half a year were compared among the four groups. According to the results of the maximum clot intensification(MA-ADP)induced by adenosine diphosphate in TEG, the patients were divided into MA-ADP <31 mm group, 31 mm ≤MA-ADP≤47 mm group and MA-ADP>47 mm group. The platelet inhibition rate and the total incidence of bleeding events were compared among the three groups. Results The platelet inhibition rate and the total incidence of ischemic events in the four groups were significantly different(P < 0.05). The platelet inhibition rate of aspirin + clopidogrel group was the highest, which was significantly higher than that of other groups(P < 0.05). The total incidence of ischemic events in aspirin + clopidogrel group was 35.00%,which was significantly higher than that in other groups(P < 0.05). The 300 patients were divided into MA-ADP <31 mm group, 31 mm < MA-ADP < 47 mm group and MA-ADP > 47 mm group according to the results of TEG MAADP. The platelet inhibition rate and the total incidence of hemorrhagic events in the three groups were significantly different(P < 0.05). The platelet inhibition rate of MA-ADP > 47 mm group was significantly lower than that of other two groups(P < 0.05). The total incidence of hemorrhage events in MA-ADP > 47 mm group was only 5%, which was significantly lower than that in other two groups(P < 0.05). Conclusion For patients receiving antiplatelet therapy after PCI, monitoring with TEG can guide the adjustment of antiplatelet therapy and ensure the inhibition of platelet aggregation activity, thus reducing the incidence of cardiovascular adverse events.
Objective To monitor the effect of antiplatelet drugs after percutaneous coronary intervention(PCI) in patients with coronary heart disease by thromboelastography(TEG), and to analyze its relationship with ischemic and hemorrhagic events after PCI. Methods A total of 300 patients with coronary heart disease diagnosed by the First People′s Hospital of Huizhou City of Guangdong Province( "our hospital" for short) and treated with PCI were collected from July 2017 to May 2018. All patients were treated with aspirin and clopidogrel for antiplatelet therapy. The arachidonic acid(AA) pathway platelet aggregation inhibition rate ≥ 50% defines Aspirin onset; the adenosine diphosphate(ADP) pathway platelet aggregation inhibition rate ≥ 30% defines Clopidogrel onset. According to the results of TEG AA/ADP inhibition rate, 200 cases were divided into Aspirin + Clopidogrel effective group(AA and ADP inhibition rates were up to standard), 30 cases in Aspirin ineffective group, 50 cases in Clopidogrel ineffective group and 20 cases in Aspirin + Clopidogrel ineffective group. The platelet inhibition rate and the total incidence of ischemic events within half a year were compared among the four groups. According to the results of the maximum clot intensification(MA-ADP)induced by adenosine diphosphate in TEG, the patients were divided into MA-ADP <31 mm group, 31 mm ≤MA-ADP≤47 mm group and MA-ADP>47 mm group. The platelet inhibition rate and the total incidence of bleeding events were compared among the three groups. Results The platelet inhibition rate and the total incidence of ischemic events in the four groups were significantly different(P < 0.05). The platelet inhibition rate of aspirin + clopidogrel group was the highest, which was significantly higher than that of other groups(P < 0.05). The total incidence of ischemic events in aspirin + clopidogrel group was 35.00%,which was significantly higher than that in other groups(P < 0.05). The 300 patients were divided into MA-ADP <31 mm group, 31 mm < MA-ADP < 47 mm group and MA-ADP > 47 mm group according to the results of TEG MAADP. The platelet inhibition rate and the total incidence of hemorrhagic events in the three groups were significantly different(P < 0.05). The platelet inhibition rate of MA-ADP > 47 mm group was significantly lower than that of other two groups(P < 0.05). The total incidence of hemorrhage events in MA-ADP > 47 mm group was only 5%, which was significantly lower than that in other two groups(P < 0.05). Conclusion For patients receiving antiplatelet therapy after PCI, monitoring with TEG can guide the adjustment of antiplatelet therapy and ensure the inhibition of platelet aggregation activity, thus reducing the incidence of cardiovascular adverse events.
引文
[1]王慧丽,杨渊,丁荣晶,等.经皮冠状动脉介入治疗术后1年患者抗血小板治疗用药依从性的调查研究[J].中华疾病控制杂志,2014,18(3):243-246.
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[4]赵树武,王玉平,徐林东,等.血栓弹力图在冠心病抗血小板治疗中的临床应用[J].中国循证心血管医学杂志,2014,6(3):328-330.
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[11]苏广智,李楠,刘岩,等.氯吡格雷联合阿司匹林对不稳定型心绞痛患者阿司匹林抵抗影响的临床研究[J].实用医药杂志,2016,33(11):983-985.
[12]陈建秋,章颖,胡彬彬,等.CYP2C19基因多态性对氯吡格雷治疗急性脑梗死的疗效影响[J].中国现代医生,2017,55(23):6-9.
[13]黄鹤,马莉.血栓弹力图的应用进展[J].现代临床医学2015,41(3):163-165.
[14]刘菁晶,林文华,敬锐,等.血栓弹力图对冠状动脉介入治疗术后抗血小板治疗的指导意义[J].现代中西医结合杂志,2017,26(22):2487-2489.
[15]刘然,师树田,索旻,等.对氯吡格雷低反应患者换用替格瑞洛后的有效性与安全性评价[J].中国介入心脏病学杂志,2014,22(1):12-17.
[16]李开亮,张帷,王海军,等.75岁以上老年冠心病患者应用不同抗血小板药物临床疗效观察[J].中华老年心脑血管病杂志,2017,19(7):712-715.
[17]陈宝婷,陈熹,赵奎君,等.氯吡格雷联合阿司匹林抗血小板聚集临床疗效的Meta分析及用药策略[J].中国现代医生,2018,56(6):98-101.
[18]冯真,刘鹏.阿司匹林联合氯吡格雷对急性脑梗死患者血小板活化及神经功能的影响[J].中国医院用药评价与分析,2018,18(6):803-804,807.
[19]陈纪林,高立建.经皮冠状动脉介入治疗术后双联抗血小板治疗研究进展[J].中国循环杂志,2014,29(3):161-162.
[20]杨红丽,刘华云,严亚林,等.心肌梗死患者经皮冠状动脉介入术术后双抗血小板治疗变替格瑞洛单抗治疗的可行性分析[J].血栓与止血学,2017,23(3):433-434.
[21]张丽君,黄淑田,王瑞英,等.经皮冠状动脉介入治疗术后冠心病患者双联抗血小板药物应用时间与预后的相关性研究[J].中国心血管杂志,2015,20(2):114-118.
[22]魏洪杰,石俊婷,李星星,等.冠脉支架术后氯吡格雷抵抗患者抗血小板药物疗效研究[J].临床和实验医学杂志,2017,16(16):1635-1638.
[23]郭一洁,邹晓,司全金.抗血小板药物研究进展[J].中华老年多器官疾病杂志,2017,16(9):699-700.
[24]龚艳君,屈晨雪,邱林,等.应用血栓弹力图评价经皮冠状动脉介入治疗术后患者抗血小板药物的治疗效果[J]中国介入心脏病学杂志,2015,23(1):18-19.
[25]李新刚,凌曦,赵坤,等.抗血小板药物抵抗的研究进展[J]中国医院用药评价与分析,2017,17(3):289-291,296.
[26]刘莹,董艳娟,魏微.血栓弹力图在缺血性脑卒中患者抗血小板药物选择中的应用[J].中国医学装备,2017,14(8):95-98.
[2]冯雪茹,刘梅林,刘芳,等.阿司匹林剂量对高龄老年患者血小板功能的影响[J].北京大学学报:医学版,2016,48(5):835-840.
[3]曹剑.阿司匹林和氯吡格雷药物抵抗的研究进展[J].武警医学,2013,24(1):1-4.
[4]赵树武,王玉平,徐林东,等.血栓弹力图在冠心病抗血小板治疗中的临床应用[J].中国循证心血管医学杂志,2014,6(3):328-330.
[5]中华医学会心血管病学分会介入心脏病学组,中华心血管病杂志编辑委员会.中国经皮冠状动脉介入治疗指南2012(简本)[J].中国医学前沿杂志,2012,4(12):50-59.
[6]Roberts ET,Horne A,Martin SS,et al.Cost-effectiveness of coronary artery calcium testing for coronary heart and cardiovascular disease risk prediction to guide statin allocation:the Multi-Ethnic Study of Atherosclerosis(MESA)[J]PLo S One,2015,10(3):e0116377.
[7]赵静.经皮冠状动脉介入治疗后双联抗血小板治疗疗程研究进展[J].中国全科医学,2017,20(21):2679-2682.
[8]彭利,张蓝宁,陈曦,等.CYP2C19功能缺失性等位基因与老年冠心病患者支架植入术后氯吡格雷抗血小板反应性和疗效的药物基因组学研究[J].中华老年多器官疾病杂志,2014,13(10):721-726.
[9]陈纪林,高立建.经皮冠状动脉介入治疗术后双联抗血小板治疗研究进展[J].中国循环杂志,2014,29(3):161-162.
[10]Hoebers LP,Claessen BE,Dangas GD,et al.Long-term clinical outcomes after percutaneous coronary intervention for chronic total occlusions in elderly patients(≥75 Years)Five-Year Outcomes from a 1791 Patient Multi-National Registry[J].Catheter Cardiovasc Interv,2013,82(1):85-92.
[11]苏广智,李楠,刘岩,等.氯吡格雷联合阿司匹林对不稳定型心绞痛患者阿司匹林抵抗影响的临床研究[J].实用医药杂志,2016,33(11):983-985.
[12]陈建秋,章颖,胡彬彬,等.CYP2C19基因多态性对氯吡格雷治疗急性脑梗死的疗效影响[J].中国现代医生,2017,55(23):6-9.
[13]黄鹤,马莉.血栓弹力图的应用进展[J].现代临床医学2015,41(3):163-165.
[14]刘菁晶,林文华,敬锐,等.血栓弹力图对冠状动脉介入治疗术后抗血小板治疗的指导意义[J].现代中西医结合杂志,2017,26(22):2487-2489.
[15]刘然,师树田,索旻,等.对氯吡格雷低反应患者换用替格瑞洛后的有效性与安全性评价[J].中国介入心脏病学杂志,2014,22(1):12-17.
[16]李开亮,张帷,王海军,等.75岁以上老年冠心病患者应用不同抗血小板药物临床疗效观察[J].中华老年心脑血管病杂志,2017,19(7):712-715.
[17]陈宝婷,陈熹,赵奎君,等.氯吡格雷联合阿司匹林抗血小板聚集临床疗效的Meta分析及用药策略[J].中国现代医生,2018,56(6):98-101.
[18]冯真,刘鹏.阿司匹林联合氯吡格雷对急性脑梗死患者血小板活化及神经功能的影响[J].中国医院用药评价与分析,2018,18(6):803-804,807.
[19]陈纪林,高立建.经皮冠状动脉介入治疗术后双联抗血小板治疗研究进展[J].中国循环杂志,2014,29(3):161-162.
[20]杨红丽,刘华云,严亚林,等.心肌梗死患者经皮冠状动脉介入术术后双抗血小板治疗变替格瑞洛单抗治疗的可行性分析[J].血栓与止血学,2017,23(3):433-434.
[21]张丽君,黄淑田,王瑞英,等.经皮冠状动脉介入治疗术后冠心病患者双联抗血小板药物应用时间与预后的相关性研究[J].中国心血管杂志,2015,20(2):114-118.
[22]魏洪杰,石俊婷,李星星,等.冠脉支架术后氯吡格雷抵抗患者抗血小板药物疗效研究[J].临床和实验医学杂志,2017,16(16):1635-1638.
[23]郭一洁,邹晓,司全金.抗血小板药物研究进展[J].中华老年多器官疾病杂志,2017,16(9):699-700.
[24]龚艳君,屈晨雪,邱林,等.应用血栓弹力图评价经皮冠状动脉介入治疗术后患者抗血小板药物的治疗效果[J]中国介入心脏病学杂志,2015,23(1):18-19.
[25]李新刚,凌曦,赵坤,等.抗血小板药物抵抗的研究进展[J]中国医院用药评价与分析,2017,17(3):289-291,296.
[26]刘莹,董艳娟,魏微.血栓弹力图在缺血性脑卒中患者抗血小板药物选择中的应用[J].中国医学装备,2017,14(8):95-98.