三联抗血小板对急性冠脉综合征患者经皮冠状动脉介入术后30天内的作用

Triple anti-platelet therapy protecting acute coronary syndrome patients from complication within 30 days after PCI

目的探究三联抗血小板（小剂量替罗非班加阿司匹林和氯吡格雷）较双联抗血小板（阿司匹林和氯吡咯雷）对预防急性冠脉综合征（ACS）患者植入药物洗脱支架（DES）后30d内支架内血栓（sT）和主要不良心脏事件（MACE）的有效性和安全性。方法回顾性搜集2004年3月到2010年11月因ACS就诊于泰达国际心血管病医院并植入DES的患者2904例，部分患者采用双联抗血小板治疗（双联组，n=1145），部分患者采用三联抗血小板治疗（三联组，n=1759），通过Fisher确切概率法比较两组患者PCI术后30d内ST、MACE及临床不良反应的发生率。结果虽然两组间患者的年龄、病变狭窄程度、吸烟、糖尿病、高脂血症和冠状动脉弥漫性病变的比率有差异，但通过Cox分析发现以上因素对终点事件的发生无影响，两组患者其余基线资料的比较差异无统计学意义。三联组主要终点事件ST的发生率低于双联组（0．11％VS．1．05％，P=0．0036），三联组较双联组相对风险降低89．52％。三联组次要终点事件MACE（包括心源性死亡、紧急靶血管血运重建、心肌梗死）的发生率也低于双联组（0．17％vs．1．48％，P=0．0005），三联组较双联组相对风险降低88．51％，其中三联组心源性死亡、紧急靶血管血运重建的发生率低于双联组，差异具有统计学意义，但两组间心肌梗死的发生率比较差异无统计学意义。两组中均无严重出血事件；三联组轻度出血事件发生8例（0．45％），双联组发生4例（0．35％），差异无统计学意义（P=0．6720）。三联组急性血小板减少症发生8例（0．45％），双联组发生1例（0．09％），差异也无统计学意义（P=0．083）。结论与双联组相比，三联组ACS患者PCI术后30d内发生sT和MACE的风险明显降低，而出血风险及急性血小板减少症的发生率并没有增加。

Objective To investigate the efficacy and safety of triple anti-platelet therapy （low-dose tirofiban plus aspirin and clopidogrel） comparing to dual anti-platelet therapy （aspirin and clopidogrel） in preventing stent thrombosis （ST） and major adverse cardiac events （MACE） within 30 days after implantation of drug-eluting stentt （DES） in ACS patients. Methods A total of 2904 ACS patients treated with DES from March 2004 to November 2010 were enrolled for retrospective study. Of them, 1145 patients were treated with dual anti-platelet therapy （DAT） and 1759 patients with triple anti-platelet therapy （TAT）. The incidences of ST, MACE （cardiac death, urgent target vessel revasculanization and myocardial infarction） and side effects occurred within 30 days after PCI were compared between two groups by Fisher＇ s exact test. Results （ 1 ） Although there were significant differences in age, the degree of coronary stenosis, the number of smokers,diabetes, hyperlipidemia and coronary diffuse lesion between two groups, but these differences did not impact on the end point events showed by Cox analysis. The rest of the general condition of patients between two groups was no difference. （2） The incidence of ST as primary end point was lower in TAT group than that in DAT group （0. 11% vs. 1.05%, P =0.0056）, reducing the relative risk by 89.52%. In addition, the incidence of MACT as secondary end point was also lower in TAT group than that in DAT group （0. 17% vs. 1.48%, P = 0. 0005）, reducing the relative risk by 88.51%. Among the total, the incidences of cardiac death and urgent target vessel re-vascularization in TAT group were lower than those in DAT group with significant differences. However, there was no difference in the incidence of myocardial infarction between two groups. （3） Both two groups had no severe hemorrhage complication, the incidence of mild hemorrhage was similar in two groups （0. 45% vs. 0. 35%, P =0. 6720）. Besides, the incidence of acute thrombocytopenia between two groups was also similar （0. 45% vs. 0. 09%, P = 0. 083）. Conclusions The patients with ACS in the TAT group have significant lower incidence of ST and MACE than those in the DAT group within 30 days after PCI. While the risk of bleeding and the incidence of acute thrombocytopenia do not increase.