谈红,胡瑛,李晓燕,苏莉,张国明,沈虹,陈英剑,李蕾

• 1:济南军区总医院心内科
• 2:济南军区总医院干部病房二科
• 3:济南军区总医院实验诊断科

摘要(Abstract)：

目的通过血栓弹力图对血小板功能的检测,探讨急性冠状动脉综合征(acute coronary syndrome,ACS)患者服用氯吡格雷经皮冠状动脉介入治疗(percutaneous coronary intervention,PCI)后,改用替格瑞洛治疗的血小板反应性。方法纳入济南军区总医院220例ACS行PCI患者,给予氯吡格雷负荷剂量后第5天进行血栓弹力图(thromboela-stogram,TEG)腺苷二磷酸(ADP)抑制率检测,根据患者ADP抑制率是否小于30%分为氯吡格雷抵抗(clopidogrel resistance,CR)组与非氯吡格雷抵抗(non clopidogrel resistance,NCR)组,每组再随机分为替格瑞洛及氯吡格雷2个亚组,采用单组同意Zelen设计调整分组,1个月后复查TEG,观察各组患者ADP抑制率变化情况。并随访患者6个月主要不良心血管事件(major adverse cardiac event,MACE)及两种药物短期不良反应。结果 1个月后复查TEG,CR患者替格瑞洛组ADP诱导的血小板抑制率显著升高[(16.9±8.5)%比(45.4±16.9)%,P<0.01],而氯吡格雷组为[(17.9±7.7)%比(18.4±8.0%),P=0.623],差异无统计学意义;NCR患者替格瑞洛组ADP诱导的血小板抑制率亦显著升高[(45.1±12.5)%与(60.2±12.4)%,P<0.01],氯吡格雷组[(49.1±14.6)%比(49.9±15.0)%,P=0.335],差异无统计学意义。6个月临床随访结果显示,27例MACE患者中,NCR患者氯吡格雷组8例(11.3%),替格瑞洛组4例(7.7%),两组间比较差异无统计学意义(P=0.557);CR患者氯吡格雷组10例(23.8%),替格瑞洛组5例(9.1%),两组间比较差异有统计学意义(P<0.05)。Kaplan-Meier生存分析显示,各组间患者累积无MACE生存率差异有统计学意义。Cox回归分析显示,ADP抑制率是减少相对危险度,降低MACE发生率的主要因素,而SYNTAX评分较高是不利因素。CR-氯吡格雷组的MACE风险分别为NCR-氯吡格雷组、CR-替格瑞洛组、NCR-替格瑞洛组的4.53倍(P<0.01)、5.65倍(P=0.01)、6.71倍(P=0.01)。服用氯吡格雷患者MACE风险是替格瑞洛患者的6.08倍(P=0.009)。患者未见心原性死亡、卒中不良事件发生;服用氯吡格雷患者中有9例(7.7%)出现轻度出血,服用替格瑞洛患者12(11.2%)例出现出血,出血发生率比较差异无统计学意义(P=0.239)。出现呼吸困难患者中,服用氯吡格雷2例(1.8%),替格瑞洛9例(8.4%),两组比较差异有统计学意义(P<0.05),呼吸困难均为轻、中度,可耐受。结论替格瑞洛与氯吡格雷相比,能够显著提高血小板抑制率,其对CR患者血小板抑制率提升更明显,可降低患者短期MACE风险,不增加出血风险,但可能增加呼吸困难发生率。

关键词(KeyWords)： 急性冠状动脉综合征;氯吡格雷抵抗;血栓弹力图;氯吡格雷;替格瑞洛

Abstract:

Keywords:

基金项目(Foundation):

作者(Author): 谈红,胡瑛,李晓燕,苏莉,张国明,沈虹,陈英剑,李蕾

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