贾珠银,瞿小丹,孙家驹,黄一伟,王军

• 1:温州市中心医院心内科温州医科大学附属定理临床学院

摘要(Abstract)：

目的探讨替格瑞洛和氯吡格雷对非ST段抬高急性冠状动脉综合征(NSTE-ACS)患者冠状动脉微循环的影响。方法选取温州市中心医院心内科2014年6月至2015年11月收治的55例NSTE-ACS患者,按随机数字法分为替格瑞洛组(28例)和氯吡格雷组(27例),两组患者在支架置入后即刻行微循环阻力指数(IMR)测定和术后24 h内测定左心室射血分数(LVEF),术后6个月再次行IMR和LVEF测定,比较两组患者IMR、LVEF的差异。结果支架置入后即刻,替格瑞洛组IMR为(26.51±16.14)U,氯吡格雷组IMR为(34.04±16.06)U,两组比较,差异无统计学意义(P=0.09);术后6个月,替格瑞洛组IMR为(17.93±9.25)U,氯吡格雷组IMR为(25.63±11.68)U,两组比较,差异有统计学意义(P=0.009)。术后24 h,替格瑞洛组LVEF为(51.14±5.37)%,氯吡格雷组LVEF为(48.78±5.62)%,两组比较,差异无统计学意义(P=0.12);术后6个月,替格瑞洛组LVEF为(59.29±7.97)%,氯吡格雷组LVEF为(54.93±7.87)%,两组比较,差异有统计学意义(P=0.046)。直线回归分析显示,IMR和LVEF存在一定的负相关(r=0.54)。结论行早期经皮冠状动脉介入治疗的NSTE-ACS患者,应用替格瑞洛相较于氯吡格雷可改善患者术后6个月冠状动脉IMR、LVEF,且IMR和LVEF存在一定的负相关。

关键词(KeyWords)： 非ST段抬高急性冠状动脉综合征;微循环阻力指数;左心室射血分数;替格瑞洛

Abstract:

Keywords:

基金项目(Foundation): 温州市2014年公益性科技计划项目(Y20140498)

作者(Author): 贾珠银,瞿小丹,孙家驹,黄一伟,王军

参考文献(References)：

• [1]Bolognese L,Carrabba N,Parodi G,et al.Impact of microvascular dysfunction on left ventricular remodeling and longterm clinical outcome after primary coronary angioplasty for acute myocardial infarction.Circulation,2004,109(9):1121-1126.
• [2]Hombach V,Grebe O,Merkle N,et al.Sequelae of acute myocardial infarction regarding cardiac structure and function and their prognostic significance as assessed by magnetic resonance imaging.Eur Heart J,2005,26(6):549-557.
• [3]van Giezen JJ,Sidaway J,Glaves P,et al.Ticagrelor inhibits adenosine uptake in vitro and enhances adenosine-mediated hyperemia responses in a canine model.J Cardiovasc Pharmacol Ther,2012,17(2):164-172.
• [4]Bonello L,Laine M,Kipson N,et al.Ticagrelor increases adenosine plasma concentration in patients with an acute coronary syndrome.J Am Coll Cardiol,2014,63(9):872-877.
• [5]Ng MK,Yeung AC,Fearon WF.Invasive assessment of the coronary microcirculation:superior reproducibility and less hemodynamic dependence of index of microcirculatory resistance compared with coronary flow reserve.Circulation,2006,113(17):2054-2061.
• [6]Aarnoudse W,Fearon WF,Manoharan G,et al.Epicardial stenosis severity does not affect minimal microcirculatory resistance.Circulation,2004,110(15):2137-2142.
• [7]Fearon WF,Low AF,Yong AS,et al.Prognostic value of the Index of Microcirculatory Resistance measured after primary percutaneous coronary intervention.Circulation,2013,127(24):2436-2441.
• [8]Martínez GJ,Yong AS,Fearon WF,et al.The index of microcirculatory resistance in the physiologic assessment of the coronary microcirculation.Coron Artery Dis,2015,26(Suppl1):e15-e26.
• [9]Amsterdam EA,Wenger NK,Brindis RG,et al.2014 AHA/ACC guideline for the management of patients with non-ST-elevation acute coronary syndromes:a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines.Circulation,2014,130(25):e344-e426.
• [10]Yong AS,Layland J,Fearon WF,et al.Calculation of the index of microcirculatory resistance without coronary wedge pressure measurement in the presence of epicardial stenosis.JACC Cardiovasc Interv,2013,6(1):53-58.
• [11]Camici PG,Crea F.Coronary microvascular dysfunction.N Engl J Med,2007,356(8):830-840.
• [12]Hombach V,Grebe O,Merkle N,et al.Sequelae of acute myocardial infarction regarding cardiac structure and function and their prognostic significance as assessed by magnetic resonance imaging.Eur Heart J,2005,26(6):549-557.
• [13]Fearon WF,Shah M,Ng M,et al.Predictive value of the index of microcirculatory resistance in patients with ST-segment elevation myocardial infarction.J Am Coll Cardiol,2008,51(5):560-565.
• [14]Reffelmann T,Kloner RA.The no-reflow phenomenon:a basic mechanism of myocardial ischemia and reperfusion.Basic Res Cardiol,2006,101(5):359-372.
• [15]Kunichika H,Ben-Yehuda O,Lafitte S,et al.Effects of glycoprotein IIb/IIIa inhibition on microvascular flow after coronary reperfusion.A quantitative myocardial contrast echocardiography study.J Am Coll Cardiol,2004,43(2):276-283.
• [16]Morrow DA,Wiviott SD,White HD,et al.Effect of the novel thienopyridine prasugrel compared with clopidogrel on spontaneous and procedural myocardial infarction in the Trial to Assess Improvement in Therapeutic Outcomes by Optimizing Platelet Inhibition with Prasugrel-Thrombolysis in Myocardial Infarction 38:an application of the classification system from the universal definition of myocardial infarction.Circulation,2009,119(21):2758-2764.
• [17]Storey RF,Husted S,Harrington RA,et al.Inhibition of platelet aggregation by AZD6140,a reversible oral P2Y12 receptor antagonist,compared with clopidogrel in patients with acute coronary syndromes.J Am Coll Cardiol,2007,50(19):1852-1856.
• [18]Gurbel PA,Bliden KP,Butler K,et al.Randomized doubleblind assessment of the ONSET and OFFSET of the antiplatelet effects of ticagrelor versus clopidogrel in patients with stable coronary artery disease:the ONSET/OFFSET study.Circulation,2009,120(25):2577-2585.
• [19]Wallentin L,Becker RC,Budaj A,et al.Ticagrelor versus clopidogrel in patients with acute coronary syndromes.N Engl J Med,2009,361(11):1045-1057.
• [20]杨敏,姜祖超,王文尧,等.替格瑞洛和氯吡格雷对急性ST段抬高心肌梗死直接经皮冠状动脉介入治疗术后慢血流的影响.中国介入心脏病学杂志,2015,23(12):677-681.
• [21]Roffi M,Patrono C,Collet JP,et al.2015 ESC guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation,Task Force for the Management of Acute Coronary Syndromes in Patients Presenting without Persistent ST-Segment Elevation of the European Society of Cardiology.Eur Heart J,2016,37(3):267-315.
• [22]徐林,金立军,何晓玲,等.替格瑞洛增加循环中腺苷浓度及介导生物学效应.中国介入心脏病学杂志,2015,23(9):522-525.
• [23]Sezer M,Oflaz H,G?ren T,et al.Intracoronary streptokinase after primary percutaneous coronary intervention.N Engl J Med,2007,356(18):1823-1836.
• [24]Cohen MV,Downey JM.Adenosine at reperfusion:a conundrum ready to be resolved.J Am Coll Cardiol,2009,53(8):718-719.
• [25]Cuculi F,De Maria GL,Meier P,et al.Impact of microvascular obstruction on the assessment of coronary flow reserve,index of microcirculatory resistance,and fractional flow reserve after STsegment elevation myocardial infarction.J Am Coll Cardiol,2014,64(18):1894-1904.
• [26]Mc Geoch R,Watkins S,Berry C,et al.The index of microcirculatory resistance measured acutely predicts the extent and severity of myocardial infarction in patients with ST-segment elevation myocardial infarction.JACC Cardiovasc Interv,2010,3(7):715-722.
• [27]Fearon WF,Low AF,Yong AS,et al.Prognostic value of the Index of Microcirculatory Resistance measured after primary percutaneous coronary intervention.Circulation,2013,127(24):2436-2441.
• [28]Cuculi F,Dall'Armellina E,Manlhiot C,et al.Early change in invasive measures of microvascular function can predict myocardial recovery following PCI for ST-elevation myocardial infarction.Eur Heart J,2014,35(29):1971-1980.