冠状动脉介入术后抗血小板治疗联合不同质子泵抑制剂对消化道出血的预防作用和心血管事件的影响

Influence of different proton pump inhibitors on prevention of gastrointestinal hemorrhage and on cardiovascular events in antiplatelet therapy after percutaneous coronary intervention

目的观察老年冠心病患者冠状动脉介入（PCI）术后氯吡格雷＋阿司匹林治疗与不同质子泵抑制剂联用在预防消化道出血及对血小板聚集率（PAR）和心血管事件发生情况的影响。方法选择符合入选条件的280例患者，在氯吡格雷十阿司匹林的基础上，随机分为5组，A组：对照组；B组：奥美拉唑20mg bid；C组：雷贝拉唑10mg bid；D组：兰索拉唑30mg qd；E组：埃索美拉唑20mg bid。治疗期间通过观察呕血、黑便、上腹不适或腹痛和反酸、烧心症状，行便隐血试验，胃镜检查，确定消化道损伤发生；同时观察心血管不良事件发生，并检测PAR。患者出院后门诊随访12个月。结果A、B、C、D、E组消化道损伤的发生率分别为28．85％、12．28％、10．53％、10．34％、8．93％；A组中出现3例消化道大出血，B、C、D、E组中均未出现；B、C、D、E四组与A组比较差异有统计学意义（P〈0．05），B、C、D、E组之间无统计学差异。A、B、C、D、E组心血管事件发生率分别为5．77％、14．04％、7．02％、8．62％、8．93％；PAR分别为22％±7％、34％±11％、27％±6％、26％±7％、23％±6％，B组心血管事件发生率与PAR明显升高。结论PCI术后，氯吡格雷＋阿司匹林治疗与质子泵抑制剂联用可明显降低患者消化道出血的发生，奥美拉唑与其联用能明显提高血小板聚集率，降低抗血小板疗效，增加心脑血管事件的发生率，其他质子泵抑制剂对其抗血小板疗效无明显影响。

Objective To study the effect of different proton pump inhibitors （PPIs） on the prevention of gastrointestinal hemorrhage and the influence to platelet aggravation rate （PAR） and cardiovascular events in elderly patients treated with clopidogrel＋aspirin after percutaneous coronary intervention （PCI）. Methods A total of 280 patients taking clopidogrel＋aspirin after PCI were randomly divided into 5 groups, including group A （control）： basic treatment （aspirin＋clopidogrel）, group B： basic treatment with omeprazole 20mg bid, group C： basic treatment with rabeprazole 10mg bid, group D： basic treatment with lansoprazole 30mg qd, group E： basic treatment with esomeprazole 20mg bid. Patients were observed for 12 months after the treatment. Patients who presented with gastrointestinal damage （hematemesis, abdominal discomfort, bellyache） received gastroscopic examination. Adverse cardiovascular events and PAR were also determined. Results The incidence of gastrointestinal injury was 28.85%, 12.28%, 10.53%, 10.34% and 8.93% in group A, B, C, D and E respectively. There was significant difference between group A and other 4 groups （P 〈 0.05）. The incidence of cardiovascular events was 5.77%, 14.04%, 7.02%, 8.62% and 8.93%, and PAR was 22% ± 7%, 34% ± 11%, 27% ＋ 6%, 26% ± 7%, and 23% ± 6% respectively. The incidence and PAR increased greatly in group B. Conclusion The gastrointestinal hemorrhage of patients treated with clopidogrel＋aspirin can be prevented safely and effectively with PPIs. Omeprazole can promote PAR and thus decrease the antiplatelet effect so as to increase the occurrance of cardiovascular events, while other PPIs hav e no influence on antiplatelet effect.