氯吡格雷抵抗对老年冠心病合并糖尿病患者介入治疗预后的影响及其危险因素

Clopidogrel resistance in elderly diabetes-complicated coronary heart disease patients treated with percutaneous coronary intervention: analysis of periprocedural outcomes and risk factors

摘要:

目的 观察接受冠脉介入治疗的合并2型糖尿病（T2DM，简称DM）的老年冠心病患者中氯吡格雷抵抗的发生情况及相应的危险因素、并评估其对介入治疗预后的影响。方法 连续选取于解放军总医院住院接受氯吡格雷治疗的合并DM的老年冠心病患者232例，进行血栓弹力图检测，ADP诱导的血小板抑制率大于50%者为对照组（n＝142），抑制率低于50%者为观察组（n＝90）。观察两组冠脉介入术前临床危险因素、糖代谢、脂代谢及炎症指标水平的差异，评价围手术期心肌梗死及死亡发生率的差异。结果 观察组与对照组的年龄、性别、体质量指数（BMI）、吸烟史、高血压及高脂血症发生率、用药情况、甘油三酯（TG）、总胆固醇（TC）、低密度脂蛋白胆固醇（LDL-C）以及糖化血红蛋白（HbA1c）水平的差异均无统计学意义（P＞0.05）。观察组的高密度脂蛋白胆固醇（HDL-C）水平明显偏低，空腹血糖（FPG）、糖化血清蛋白（GSP）以及超敏C反应蛋白（hs-CRP）水平明显增高（均P＜0.01）。与对照组相比，观察组院内发生围手术期心肌梗死的比例明显升高（P＜0.01），死亡发生率的差异则无统计学意义（P＞0.05）。结论 合并DM的老年冠心病患者存在明显氯吡格雷抵抗现象，氯吡格雷抵抗患者术后心肌梗死的风险明显增加，FPG、GSP、hs-CRP水平增高与HDL-C水平降低可能是老年患者氯吡格雷抵抗的危险因素。

Abstract:

Objective To evaluate the incidence and possible risk factors of clopidogrel resistance in elderly patients with diabetes and coronary heart disease treated with percutaneous coronary intervention, and to investigate the impact of clopidogrel resistance on post-procedural outcomes. Methods Total 232 elderly inpatients with diabetes and coronary heart disease who were treated with clopidogrel and percutaneous coronary intervention were consecutively enrolled in this study. After receiving TEG test, the patients were divided into two groups according to ADP dependent platelet inhibition ratio: the control group (ratio＞50%) and the study group (ratio＜50%). The profiles of clinical cardiovascular risk factors, lipid and glucose metabolic indices, inflammation indices were collected before coronary intervention and compared between two groups. The incidence of post-procedural in-hospital myocardial infarction and mortality were also compared between two groups. Results There was no difference in age, gender, body mass index, history of smoking, incidences of hypertension and hyperlipidermia, medication, levels of triglyceride, total cholesterol, low density lipoprotein cholesterol and hemoglobin A1c between two groups. The patients in study group had lower level of high density lipoprotein cholesterol(HDL-C) and higher levels of fasting glucose, glucosylated serum protein(GSP) and high sensitivity C reactive protein(hs-CRP) than patients in control group (P＜0.01 for all). The study group had higher rate of post-procedural myocardial infarction than the control group (P＜0.01). No difference of mortality rate was found between two groups. Conclusions Clopidogrel resistance is common in elderly patients with diabetes and coronary heart disease. Elderly patients with clopidogrel resistance showed higher risk of in-hospital myocardial infarction after coronary intervention. Elevated levels of fasting glucose, GSP and hs-CRP and low level of HDL-C may suggest high risk of clopidogrel resistance in elderly patients with diabetes and coronary heart disease.