血栓弹力图指导的抗血小板治疗对支架内再狭窄患者预后的影响

Effect of thrombelastography-guided antiplatelet therapy on prognosis of in-stent restenosis patients

摘要:

目的 探讨血栓弹力图检查指导下的双联抗血小板治疗对经皮冠状动脉介入治疗(PCI)术后支架内再狭窄(ISR)患者临床预后的影响。方法 选取2017年1月至2020年1月中国人民解放军总医院第一医学中心心血管内科收治的经冠状动脉造影确诊为PCI术后ISR的患者275例。完善血栓弹力图(TEG)检查,根据二磷酸腺苷(ADP)途径诱导的血小板抑制率(ADP抑制率)和ADP途径曲线最大振幅(MA)是否达标,将患者分为对照组(n=184)、氯吡格雷组(n=57)和替格瑞洛组(n=34),给予阿司匹林联合氯吡格雷或替格瑞洛治疗。出院后每6个月随访一次,分析3组患者长期预后的差异。采用SPSS 25.0软件进行统计分析。采用logistic回归法分析影响ISR患者预后的危险因素。结果 随访时间15～52[26(18,34)]个月。对照组患者ADP抑制率显著高于氯吡格雷组和替格瑞洛组[(85.63±13.57)%和(37.60±8.19)%,(22.74±9.76)%；P＜0.05]；替格瑞洛组MA-ADP显著高于对照组及氯吡格雷组[(52.16±4.82)和(17.01±9.08),(38.69±4.68)mm；P＜0.05]。替格瑞洛组换药后ADP抑制率显著升高[(22.74±9.76)%和(81.04±15.01)%],MA-ADP显著降低[(52.16±4.82)和(17.06±9.26)mm],差异均有统计学意义(均P＜0.05)。氯吡格雷组的主要不良心血管事件(MACE)发生率和全因死亡率显著高于对照组和替格瑞洛组(均P＜0.05)。ADP抑制率是ISR患者治疗术后再次入院、行冠状动脉造影检查、再次PCI、心源性死亡及MACE的保护性因素。随着ADP抑制率的升高,MACE发生率显著降低(OR=0.56,95%CI 0.42～0.76；P＜0.001)。结论 ADP抑制率是ISR患者治疗术后MACE事件发生的保护因素,在TEG指导下采用有效的DAPT方案可以显著降低ISR患者MACE发生率,改善患者预后。

Abstract:

Objective To explore the effect of thrombelastography (TEG) guided dual antiplatelet therapy (DAPT) on clinical prognosis of in-stent restenosis (ISR) patients after percutaneous coronary intervention (PCI). Methods A total of 275 patients diagnosed with ISR after PCI by coronary angiography (CAG) who were admitted to the Department of Cardiology, First Medical Center of Chinese PLA General Hospital from January 2017 to January 2020 were recruited in this study. All of them received TEG examination, and according to adenosine diphosphate pathway-induced platelet inhibition rate (ADP inhibition rate) and maximum amplitude of ADP (MA-ADP), the patients were divided into control group (n=184), clopidogrel group (n=57) and ticagrelor group (n=34), being given aspirin combined with clopidogrel or ticagrelor for treatment. All of the patients were followed up every 6 months after discharge, and their long-term prognosis were compared among the 3 groups. SPSS 25.0 software was used for statistical analysis. Logistic regression analysis was employed to screen the risk factors for the prognosis of ISR patients. Results The follow-up time was 15-52 [26 (18,34)] months. The control group exhibited significantly higher ADP inhibition rate than the clopidogrel group and ticagrelor group [(85.64±13.57)% vs (37.60±8.19)% and (22.74±9.76)%; P<0.05). The MA-ADP was significantly higher in the ticagrelor group than the control group and the clopidogrel group [(52.16±4.82) vs (17.01±9.08)and (38.69±4.68)mm; P<0.05]. In the ticagrelor group, the ADP inhibition rate was increased from (22.74±9.76)% to (81.04±15.01)%, and the MA-ADP was decreased from (52.16±4.82) to (17.06±9.26) mm after drug change (P<0.05). The incidence of major adverse cardiovascular events (MACE) and all-cause mortality were significantly higher in the clopidogrel group than the other 2 groups (P<0.05). ADP inhibition rate was a protective factor for re-admission, coronary angiography, re-PCI and cardiovascular death and MACE in patients with ISR after treatment. With the increase of ADP inhibition rate, the MACE rate was decreased obviously (OR=0.56, 95%CI 0.42-0.76; P<0.001). Conclusion The ADP inhibition rate is a protective factor for MACE after ISR treatment. TEG-guided effective DAPT treatment can significantly reduce the incidence rate of MACE and improve the prognosis in ISR patients.