华南地区经皮冠状动脉介入术后服用双重抗血小板药物患者上消化道出血的发生率、临床特征及危险因素分析

The incidence, clinical characteristics and risk factors of upper gastrointestinal bleeding in patients taking dual antiplatelet therapy after percutaneous coronary intervention in south China

目的 探讨急性冠状动脉综合征（ACS）患者经皮冠状动脉介入术（PCI）后服用双重抗血小板药物的上消化道出血（UGIB）发生率、临床特征及危险因素.方法 回顾性分析2009年9月至2014年8月就诊于广东省人民医院因ACS而行PCI治疗的患者资料.分析患者服用阿司匹林联合氯吡格雷双重抗血小板治疗1年内的UGIB发生率和临床特点,采用1：3的比例进行性别、年龄匹配,筛选发生UGIB的相关危险因素.结果 2009年9月至2014年8月共有9118例PCI术后的ACS患者纳入研究,期间有189例（2.07％,189/9118）发生UGIB.除外术后1年以上、合并消化道肿瘤、静脉曲张和胃镜阴性的UGIB,PCI术后1年内的UGIB发生率为0.61％ （56/9118）,呈现逐年下降趋势.绝大多数患者（91.07％,51/56）表现为黑便或粪潜血阳性,其余为血便或呕血.胃镜下表现以溃疡相关性为主,占67.86％（38/56）,其中十二指肠球部溃疡24例、胃溃疡13例,复合溃疡1例,其余为胃糜烂、胃炎或十二指肠球炎.PCI术后发生UGIB的危险因素包括既往有消化性溃疡病史（OR=25.57,95％CI2.88～ 227.16,P＜0.01）和肾功能不全（OR =2.93,95％CI 1.34～6.44,P＜0.01）;保护因素为使用质子泵抑制剂（PPI）（OR =0.44,95％ CI 0.20 ～0.98,P＜0.05）.预防性使用PPI的患者新发ACS的发生率为1.44％ （50/3464）,未预防性使用PPI的患者发生率为1.34％（76/5654）,两组的差异无统计学意义（P＞0.05）,即PCI术后为预防UGIB的发生而使用PPI并不增加ACS的发生率.结论 ACS患者PCI术后服用阿司匹林联合氯吡格雷双重抗血小板治疗1年内UGIB的发生率为0.61％,呈现逐年下降趋势.PPI使用有助于预防PCI术后发生UGIB,尤其对既往有消化性溃疡病史和肾功能不全的患者.

Objective To investigate the incidence,clinical characteristics and risk factors of upper gastrointestinal bleeding （UGIB） in patients with acute coronary syndrome （ACS） who were administrated with aspirin and clopidogrel dual antiplatelet therapy after percutaneous coronary intervention （PCI）.Methods ACS patients who had undergone PCI in the cardiovascular institute of Guangdong General Hospital from September 2009 to August 2014 were retrospectively enrolled.The incidence of UGIB and clinical characteristics of ACS patients on dual antiplatelet therapy for 1 year after PCI were analyzed.Risk factors of UGIB were screened in the cohort of patients and sex and age matched controls with ratio 1：3.Results A total of 9 118 ACS patients had undergone PCI and UGIB occurred in 189 patients （2.07%,189/9 118） from September 2009 to August 2014.UGIB patients with history over one year,gastrointestinal tumors or varices or negative endoscopy were excluded.Thus the revised incidence of UGIB occurred was 0.61% in 56 patients （0.61%,56/9 118） and appeared to decline year by year.Most patients （91.07%,51/56） had melena or stool occult blood positive （OB ＋）,while others had bloody stool or haematemesis.Most UGIB were ulcer-related which was proved by endoscopy,accounting for 67.86%（38/56）.There were 24 cases with duodenal ulcer,13 with gastric ulcer and 1 with complex ulcer,while others were gastric erosion,gastritis and duodenitis.The risk factors of UGIB were previous history of peptic ulcer （P 〈 0.01） and renal impairment （P 〈 0.01）.On the other side,PPI intake was a protective factor （P 〈 0.05）.The incidence of new-onset ACS was 1.44% （50/3 464） in PPI group,compared with 1.34%（76/5 654） in no PPI group （P 〉 0.05）.PPI use for the prevention of UGIB after PCI didn＆#39;t increase the recurrence of ACS.Conclusions The incidence of UGIB is 0.61% in ACS patients on dual antiplatelet therapy （aspirin and clopidogrel） for 1 year after PCI and falls year by year.Administration of PPI after PCI protects patients from UGIB,especially in those with precious history of peptic ulcer and renal impairment.