氯吡格雷对冠状动脉旁路移植术临床与出血事件的影响

Effect of clopidogrel premedication on clinical outcomes and bleeding complications in patients undergoing coronary artery bypass graft surgery

目的 比较冠状动脉旁路移植术（CABG）前使用氯吡格雷及停用氯吡格雷时间对围手术期出血和院内主要不良心脑血管事件（MACCE）的影响.方法 入选2003年07月到2005年09月于北京安贞医院行CAJBG患者2021例.根据术前是否使用氯吡格雷分为未使用组（n=1542）和使用组（n=479）.根据术前停用氯吡格雷时间将使用组分为停用〈5 d组（n=154）,5～7 d组（n=183）和〉7 d组（n=142）.回顾性分析各组间院内MACCE事件和围手术期出血及输血情况.统计学方法采用t检验、卡方检验、方差分析.结果 未使用和使用组的围手术期出血及院内MACCE事件发生率差异无统计学意义.停用〈5 d组,5～7 d组和〉7 d组三组院内MACCE事件、所有出血和小出血发生率以及输注悬浮红细胞、新鲜冰冻血浆与全血量差异无统计学意义;三组大出血发生率和输注血小板量存在显著差异,停用〈5 d组明显高于停用5～7 d组[47.8%vs.31.9%P〈0.017;（0.08±0.38）U vs.（0.00±0.00）u,P〈0.017]或〉7 d组[47.8%、vs.20.3%P〈0.017;（0.08±0.38）Uvs.（0.00±0.00）U P〈0.017],停用5～7 d组与7 d组之间无差异.结论 冠状动脉旁路移植术前使用氯吡格雷并不增加院内主要不良心脑血管事件,术前使用氯吡格雷并停药时间不足5 d围手术期大出血发生率较高.

Objective To evaluate the effect of clopidogrel premedication on in-hospital major adverse cardiovascular and cerebral events （MACCE） and bleeding outcomes before coronary artery bypass graft surgery （CABG）. Method A total of 2021 patients who underwent CABG from July 2003 to September 2005 were divided into either clopidogrel （ n = 479） or no clopidogrel （1542） group before CABG. Patients with clopidogrel administration （ n = 479） were subdivided into 〈 5 d （ n = 154） ,5～7d（n = 183）and 〉7d（n = 142） group according to timing of clopidogrel withdrawal before surgery. In-hospital MACCE and perioperative bleeding outcomes were analyzed among groups. Results Patients who took clopidogrel before surgery had nonsignificantly rates of bleeding and in-hospital MACCE compared with those patients not administered clopidogrel. No differences were found about the incidence of total bleeding,minor bleeding,transfusions of red blood cells,fresh frozen plasma,whole blood and in-hosptial MACCE among three subgroups.The 〈 5 d group had higher incidence of major bleeding and more platelets transfusions than 5 ～ 7 d [47.8% vs. 31.9%,P 〈 0.017; （0.08 ±0.38） U vs. （0.00±0.00） U,P 〈0.017,respectively]and 〉7 d group [47.8% vs. 20.3%,P 〈0.017; （0.08±0.38） U vs. （0.00±0.00） U,P 〈0.017,respectively）. However,there were no significant differences between 5 ～ 7 d and 〉 7 d group （ P 〉 0.05）. Conclusions Gopidogrel administration before CABG does not increase the incidence of in-hospital MACCE events. However,the perioperative risk of bleeding will rise if the patients withhold clopidogrel less than five days before surgery.