半量替罗非班在老年冠状动脉旁路移植术前过渡期应用的疗效及安全性分析

Efficacy and safety of half-dose tirofiban in elderly patients during preoperative period of coronary artery bypass grafting

摘要:

目的 探讨半量的血小板GpⅡb/Ⅲa受体拮抗剂替罗非班（tirofiban）在老年冠状动脉旁路移植术（CABG）前过渡期应用的疗效和安全性。方法 入选2012年1月1日至2014年12月31日就诊于泰山医学院附属菏泽市立医院并诊断为非ST段抬高的急性冠状动脉综合征（NSTE-ACS）、经冠状动脉造影（CAG）证实为严重的三支病变和（或）左主干病变并需外科CABG的患者117例。患者年龄60～75（67.76±3.07）岁。停止双联抗血小板药物治疗后，采用随机数字法将患者分为半量替罗非班＋低分子肝素（LMWH）组（A组，60例）和单纯LMWH组（B组，57例）。其中，A组造影后持续应用半量替罗非班至术前12h停用；B组仅单纯使用LMWH；所有患者造影后给予LMWH皮下注射至术前24h，并予常规药物治疗。比较两组患者的基线资料、过渡期主要不良心血管事件（MACE，如顽固性心绞痛发作、非致死性心肌梗死、恶性心律失常及心脏性死亡等）和出血情况。结果 加用替罗非班组和单纯LMWH组比较，患者的基线资料差异无统计学意义（P＞0.05）。过渡期主要不良心血管事件中，顽固性心绞痛发作差异有统计学意义[33.3%（20/60） vs 57.9%（33/57），P＝0.01]，加用替罗非班组较单纯LMWH组减少；加用替罗非班组非致死性心肌梗死、恶性心律失常及心脏性死亡事件的发病人数较单纯LMWH组减少。术前加用替罗非班组发生轻微出血2例（鼻出血1例、痔疮出血1例），单纯LMWH组发生轻微出血1例（为牙龈出血），术中出血量及术后输血量两组比较差异均无统计学意义[术中：（564.17±125.58） vs （542.46±94.46）ml，P＝0.30；术后：（4.63±1.40） vs （4.39±1.28）u，P＝0.32]。结论 对于拟行CABG的NSTE-ACS老年患者术前持续加用替罗非班组较单纯使用LMWH作为过渡，可以有效降低心血管事件，且不增加围手术期的出血风险。

Abstract:

Objective To investigate the efficacy and safety of half-dose tirofiban, a platelet glycoprotein Ⅱb/Ⅲa receptor antagonist, in the elderly patients during preoperative transition period before receiving coronary artery bypass grafting. Methods A total of 117 patients [aged 60?75(67.76±3.07) years] with non-ST segment elevation acute coronary syndrome(NSTE-ACS) admitted to our hospital from January 2012 to December 2014 were enrolled in this study. All the patients were diagnosed as three-vessel disease and/or left main coronary diseases by coronary arteriography, and required surgical treatment of coronary artery bypass grafting (CABG). Upon termination of dual antiplatelet therapy, the cohort was randomly divided into half-dose tirofiban plus low molecular weight heparin (LMWH) group (group A, n＝60), and simple LMWH group (group B, n＝57). The patients of group A were subjected to half-dose tirofiban after coronary arteriography till 12h before the surgery and subcutaneous injection of LMWH till 24h before surgery. While those of group B only received subcutaneous injection of LMWH as in group A. Additionally, conventional medical treatment was also given to each patient. The following parameters were compared between the 2 groups, including baseline levels, bleeding, as well as major adverse cardiovascular events (MACE) during transition period, such as intractable angina, nonfatal myocardial infarction, malignant arrhythmia and cardiac death. Results No significant difference was found in the baseline data between the 2 groups (P＞0.05). For the MACEs, the incidence of intractable angina was lower in group A than in group B [33.3% (20/60) vs 57.9% (33/57), P＝0.01], and so were those of nonfatal myocardial infarction, malignant arrhythmia and cardiac death, though no significant difference was observed (P＞0.05). In group A, epistaxis (n＝1) and hemorrhoidal bleeding (n＝1) was noted, while in group B, 1 case with gum bleeding was seen. No statistical difference was observed in the amounts of bleeding during and after operation between the 2 groups [intra-operative: (564.17±125.58) vs (542.46±94.46)ml, P＝0.30; post-operative (4.63±1.40) vs (4.39±1.28)u; P＝0.32]. Conclusion Compared with simple LMWH, continued preoperative administration of half-dose tirofiban in combination with LMWH can effectively decrease the incidence of adverse cardiovascular events, but have no effect on the bleeding volume during peri-operative period in the elderly NSTE-ACS patients undergoing CABG.