不同双重抗血小板治疗时间对药物洗脱支架极晚期血栓患者预后的影响

Effect of duration for dual antiplatelet therapy on long-term prognosis in patients with very late stent thrombosis after drug-eluting stent implantation

摘要:

目的 分析药物洗脱支架（DES）术后发生极晚期支架内血栓（VLST）的患者接受双重抗血小板治疗（DAPT）的情况，探讨不同DAPT持续时间对患者远期预后的影响。方法 2006年1月至2013年2月，首都医科大学附属北京朝阳医院心脏中心共完成3 945例急诊冠状动脉造影，入选经急诊造影证实为VLST的患者。根据随访期间是否仍持续使用DAPT，将患者分为持续DAPT组和对照组。比较两组患者的临床资料、造影及介入治疗资料以及抗血小板药物治疗情况。临床主要不良心血管事件（MACE）包括随访期间的非致死性心肌梗死（MI），再发支架内血栓（ST），靶血管重建率（TVR）以及死亡。探讨不同DAPT持续时间对患者远期预后的影响，并分析随访期间发生MACE的预测因素。结果 共计有62例VLST患者纳入研究，其中男性55例，女性7例，年龄41～82（58.6±10.2）岁。VLST距第1次DES置入时间为12.5～84（38.7±18.1）个月。住院期间脑出血死亡1例，存活的61例患者随访5～88（32.1±19.1）个月。随访期间，又有17例患者出现MACE，Kaplan-Meier生存率分析提示无事件生存率为45.1%。末次随访时，坚持持续DAPT的患者38例，其中5例（13.2%）发生MACE，事件发生率明显低于对照组（54.2%，P＝0.001）。根据是否发生MACE事件将所有患者分为两组，Cox单因素分析提示再次置入第一代DES[危害率（hazard ratio，HR）：2.69，P＝0.04]和持续DAPT（HR：0.25，P＝0.01）为远期随访中MACE相关的预测因素。而多因素Cox分析则提示仅有持续DAPT是随访期间不发生MACE的唯一预测因素（HR：0.30，95% CI：0.09～0.97，P＝0.04）。结论 DES术后VLST患者远期预后情况欠佳，事件发生率较高。坚持DAPT可能有助于减少远期不良事件的发生。

Abstract:

Objective To study the application of dual antiplatelet therapy (DAPT) in the patients with very late stent thrombosis (VLST) after implantation of drug-eluting stent (DES), and to determine the effect of different durations of DAPT on long-term prognosis of these patients. Methods All of the patients with angiographically defined VLST out of 3 945 patients undergoing emergent coronary angiography in our heart center from January 2006 to February 2013 were recruited in this study. The patients were divided into 2 groups according to whether receiving continuous DAPT after implantation. The clinical data, angiographic results and interventional data were compared between the 2 groups. Major adverse cardiac events (MACE) including nonfatal myocardial infarction (MI), recurrence of stent thrombosis (ST), target vessel revascularization (TVR), and death in all causes were compared to determine the different durations of DAPT on the prognosis. Predictors of MACE during long-term follow-up were confirmed in these patients. Results Sixty-two patients were enrolled, consisting of 55 males and 7 females, with age from 41 to 82 (58.6±10.2) years. The time from first implantation of DES to occurrence of VLST was from 12.5 to 84 (38.7±18.1) months. One patient died in hospital due to cerebral hemorrhage. The other 61 patients survived to discharge, and MACE occurred in 17 patients of them during follow-up of 5 to 88 (32.1±19.1) months. Kaplan-Meier survival analysis showed the estimated MACE-free survival was 45.1%. Compared with the patients without continuous DAPT (n＝24, 13/24, 54.2%), the MACE rate was obviously lower in those with continuous DAPT (n＝38, 5/38, 13.2%, P＝0.001). Based on the occurrence of MACE, univariate Cox analysis revealed the independent predictors for MACE-free were re-implantation of the first-generation of DES [hazard ratio (HR): 2.69, P＝0.04] and continuous DAPT (HR: 0.25, P＝0.01) during our long-term follow-up. Multivariate COX analysis indicated that continuous DAPT was the only predictor for MACE-free (HR: 0.30, 95% CI: 0.09 to 0.97, P＝0.04). Conclusion Long-term outcomes for DES patients having VLST are unfavorable, with high incidence of MACE. So, continuous DAPT should be prescribed to prevent long-term MACE.