金彦彦,白融,叶明,艾辉,曾玉杰,聂绍平

• 1:首都医科大学附属北京安贞医院急诊危重症中心
• 2:首都医科大学附属北京安贞医院心内科

摘要(Abstract)：

目的探讨不同抗血小板治疗策略对接受急诊经皮冠状动脉介入治疗(PCI)的急性ST段抬高型心肌梗死(STEMI)患者冠状动脉血流及预后的影响。方法回顾性分析2016年11月至2017年11月在北京安贞医院行急诊PCI术的STEMI患者460例。按照急诊PCI术前接受不同抗血小板治疗策略分组为:低负荷氯吡格雷组169例、高负荷氯吡格雷组138例和替格瑞洛组153例。比较三组患者的一般临床情况、冠状动脉病变情况、PCI术后冠状动脉血流情况、超声心动图、生化指标、院内死亡及院内主要不良心脑血管事件(MACCE)。并将其危险因素进行logist多因素回归分析。结果三组患者在性别、年龄、体重、进入医院大门至球囊扩张时间(门-球时间)、相关病史及既往血运重建等项比较,差异均无统计学意义(均P>0.05)。三组患者相关生化指标比较,差异均无统计学意义(均P>0.05)。三组患者左心室舒张末期内径、左心室收缩末期内径及左心室射血分数比较,差异均无统计学意义(均P>0.05)。三组患者心肌梗死部位、术前心肌梗死溶栓治疗试验(TIMI)血流分级、靶血管及病变支数比较,差异均无统计学意义(均P>0.05)。三组患者慢血流/无复流情况比较,差异有统计学意义(P=0.047),低负荷氯吡格雷组患者显著高于替格瑞洛组患者(21.3%比11.8%,P=0.022),差异有统计学意义,低负荷氯吡格雷组患者高于高负荷氯吡格雷组患者(21.3%比13.8%, P=0.087),高负荷氯吡格雷组患者稍高于替格瑞洛组患者,差异均无统计学意义(13.8%比11.8%,P=0.097)。三组患者院内死亡率比较,差异有统计学意义(P=0.034),低负荷氯吡格雷组患者显著高于替格瑞洛组患者(4.1%比0.7%, P=0.043),高于高负荷氯吡格雷组患者(4.1%比0.7%,P=0.045),差异均有统计学意义;高负荷氯吡格雷组患者与替格瑞洛组患者比较,差异无统计学意义(0.7%比0.7%,P=0.077)。行logist多因素回归分析发现,慢血流/无复流(OR 12.562,95%CI2.975～53.035,P=0.001)是接受急诊PCI的STEMI患者院内死亡的独立预测因素。Spearman’s相关性分析发现,慢血流/无复流和双联抗血小板策略密切相关(r=–0.104,P=0.018)。结论在行急诊PCI术的STEMI患者中,与低负荷氯吡格雷相比,替格瑞洛可能通过减少慢血流/无复流的发生,从而降低院内死亡率。

关键词(KeyWords)： 急性ST段抬高型心肌梗死;替格瑞洛;氯吡格雷;慢血流/无复流

Abstract:

Keywords:

基金项目(Foundation):

作者(Author): 金彦彦,白融,叶明,艾辉,曾玉杰,聂绍平

参考文献(References)：

• [1]Levine GN,Bates ER,Bittl JA,et al.2016 ACC/AHA guideline focused update on duration of dual antiplatelet therapy in patients with coronary artery disease:a report of the American College of Cardiology/American Heart Association task force on clinical practice guidelines.J Am Coll Cardiol,2016,68(10):1082-1115.
• [2]中华医学会心血管病学分会介入心脏病学组,中国医师协会心血管内科医师分会血栓防治专业委员会,中华心血管病杂志编辑委员会.中国经皮冠状动脉介入治疗指南(2016).中华心血管病杂志,2016,44(5):382-400.
• [3]Ibanez B,James S,Agewall S,et al.2017 ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation:the task force for the management of acute myocardial infarction in patients presenting with ST-segment elevation of the European Society of Cardiology(ESC).Eur Heart J,2018,39(2):119-177.
• [4]Springthorpe B,Bailey A,Barton P,et al.From ATP to AZD6140:The discovery of an orally active reversible P2Y12,receptor antagonist for the prevention of thrombosis.Bioorg Med Chem Lett,2007,17(21):6013-6018.
• [5]Nylander S,Femia EA,Scavone M,et al.Ticagrelor inhibits human platelet aggregation via adenosine in addition to P2Y12 antagonism.JThromb Haemost,2013,11(10):1867-1876.
• [6]Armstrong D,Summers C,Ewart L,et al.Characterization of the adenosine pharmacology of ticagrelor reveals therapeutically relevant inhibition of equilibrative nucleoside transporter 1.J Cardiovasc Pharmacol Ther,2014,19(2):209-219.
• [7]Brosh D,Assali AR,Mager A,et al.Eff ect of no-refl ow during primary percutaneous coronary intervention for acute myocardial infarction on six-month mortality.Am J Cardiol,2007,99(4):442-445.
• [8]Gibson CM,Murphy SA,Morrow DA,et al.Angiographic perfusion score:an angiographic variable that integrates both epicardial and tissue level perfusion before and after facilitated percutaneous coronary intervention in acute myocardial infarction.Am Heart J,2004,148(2),336-340.
• [9]孙艺红.心肌血运重建治疗中的抗血小板治疗--解读2018年欧洲心脏病学会和欧洲心胸外科协会血运重建指南.中国介入心脏病学杂志,2018,26(10):543-546.
• [10]杨丽霞,郭瑞威.《中国经皮冠状动脉介入治疗指南(2016)》指导急性冠状动脉综合征的临床实践.中国介入心脏病学杂志,2016,24(12):714-717.
• [11]Wallentin L,Richard BC,Budaj A,et al.Ticagrelor versus clopidogrel in patients with acute coronary syndromes.N Engl JMed,2009,361(11):1045-1057.
• [12]Sahlén A,Varenhorst C,Lagerqvist B,et al.Outcomes in patients treated with ticagrelor or clopidogrel af ter acute myocardial infarction:experiences from SWEDEHEART registry.Eur Heart J,2016,37(44):3335-3342.
• [13]Park KH,Jeong MH,Ahn Y,et al.Comparison of shortterm clinical outcomes between ticagrelor versus clopidogrel in patients with acute myocardial infarction undergoing successful revascularization;from Korea Acute Myocardial Infarction RegistryNational Institute of Health.Int J Cardiol,2016,215:193-200.
• [14]Niccoli G,Burzotta F,Galiuto L,et al.Myocardial No-Reflow in Humans.J Am Coll Cardiol,2009,54(4):281-292.
• [15]Lerman A,Holmes DR,Herrmann J,et al.Microcirculatory dysf unction in ST-elevation myocardial inf arction:cause,consequence,or both?Eur Heart J,2007,28(7):788-797.
• [16]Rezkalla SH,Kloner RA.No-reflow phenomenon.Circulation,2002,105(5):656-662.
• [17]王永,杨慧敏,陈燕,等.冠状动脉慢血流现象临床因素分析与内皮功能评价.中国介入心脏病学杂志,2018,26(9):517-522.
• [18]Wittfeldt A,Emanuelsson H,Branarup-Wognsen G,et al.Ticagrelor enhances adenosine-induced coronary vasodilatory responses in humans.J Am Coll Cardiol,2013,61(7):723-727.
• [19]Bonello L,Kipson N,Mancini J,et al.Reply:Adenosine plasma concentration increase by ticagrelor in patients with acute coronary syndrome:no cause for fear in clinical practice.J Am Coll Cardiol,2014,63(22):2436-2437.
• [20]Navarese EP,Buffon A,Andreotti F,et al.Adenosine improves post‐procedural coronary fl ow but not clinical out-comes in patients with acute coronary syndrome:ameta‐analysis of randomizedtrials.Atherosclerosis,2012,222(1):1‐7.
• [21]Mcintosh VJ,Lasley RD.Adenosine receptor-mediated cardioprotection:are all 4 subtypes required or redundant?JCardiovasc Pharmacol Ther,2012,17(1):21-33.
• [22]Ye Y,Birnbaum GD,Perez-Polo JR,et al.Ticagrelor protects the heart against reperfusion injury and improves remodeling after myocardial infarction.Arterioscler Thromb Vasc Biol,2015,35(8):1805-1814.
• [23]Wihlborg AK,Wang L,Braun OO,et al.ADP receptor P2Y12 is expressed in vascular smooth muscle cells and stimulates contraction in human blood vessels.Arterioscler Thromb Vase Biol,2004,24(10):1810-1815.