负荷量西洛他唑对PCI围手术期心肌梗死的预防作用

Adjunctive loading dose of Cilostazol in preventing periprocedural myocardial infarction

目的探讨经皮冠状动脉介入治疗（PCI）术前应用负荷量西洛他唑、阿司匹林、氯吡格雷，继以术后维持量三联抗血小板治疗（TA阿）1周对围手术期心肌梗死（PMI）和随访1个月时主要不良心血管事件发生率的影响。方法入选2014年6月至2015年5月在天津医科大学第二医院心脏科住院并行PCI治疗的冠心病患者113例。采用随机数字表法进行分组，57例接受阿司匹林（300mg负荷，继以100mgQd，）、氯吡格雷（300mg负荷，继以75mgQd）双联抗血小板治疗（DAPT），56例在DAPT基础上加用西洛他唑（100mg负荷，继以50mgBid，TAPT组）。本研究进行了两项亚组分析：用药亚组（此次人院前正在应用阿司匹林和（或）氯吡格雷者，n=57）和未用药亚组（此次入院前未应用阿司匹林、氯吡格雷和其他抗血小板药物者，n=56）。测定PCI术前，术后8h、24h的CK—MB、cTnI、hs—CRP水平，确定PMI发生率。结果PMI总体发生率为39．8％。TAPT组与DAPT组PMI发生率未见统计学差异（32．1％tE47．4％，P=0．098）。未应用抗血小板药物患者中，TA胛组较DAPT组PMI发生率明显下降（17．9％比42．9％，P=0．042）；而应用抗血小板药物者，两组PMI发生率未见统计学差异（46．4％比51．7％，P=-0．689）。整体研究人群的多因素Cox回归分析表明，已应用抗血小板药物[风险比（HR）=2．45；95％可信区间（c，）1．09-5．52；P=0．030]与PMI发生呈显著性正相关，而是否接受TA胛与PMI未见显著性相关。结论与DAPT相比，加用西洛他唑的TAPT对未应用抗血小板药物的患者能显著降低PCI相关PMI发生率；对于已应用抗血小板药物者，TA胛则未显示相似的有益作用。

Objective Periprocedural myocardial infarction （PMI） is a common complication following percutaneous coronary intervention （PCI）. The present study was aimed to evaluate the safety and efficacy of ad- junctive loading dose of Cilostazol before PCI followed with maintenance dose for 1 week in preventing PMI in pa- tients undergoing PCI. Methods The present study enrolled a total of 113 patients with coronary artery disease who underwent PCI from Jun 2014 to May 2015 in Cardiology Department of the Second Hospital of Tianjin Medi- cal University. The patients were randomized to receive dual antiplatelet therapy （Aspirin plus Clopidogrel, DAPT group, n=57 ） or triple antiplatelet therapy（Aspirin plus Clopidogrel plus Cilostazol, TAPT group, n=56）. Loading doses of Aspirin, Clopidogrel and Cilostazol were administered immediately after the randomization. The loading and maintenance doses were 300 and 100 mg QD for Aspirin, 300 and 75 mg QD for Clopidogrel, and 100 and 50 mg Bid for Cilostazol. In addition, 2 subgroup analyses were preformed： （1）antiplatelet-treated subgroup （patients who were using Aspirin or Clopidagrel before hospitalization were assigned to antiplatelet-treated subgroup, n=57）; （2）antiplatelet-naive subgroup （Antiplatelet-naive subgroup was defined as patients who didn＇t use As- pirin, Clopidogrel or other antiplatelet agent before hospitalization, n=56）. Blood samples were collected before PCI, 8 and 24 hours after the procedure to determine the incidence of PMI. Results The overall incidence of PMI was 39.8%. The incidence of PMI were comparable between the TAPT group and the DAPT group （32.1% vs 47.4%, P=0.098）. In the antiplatelet-naive patients subgroup, TAPT group showed a significantly lower incidence of PMI compared to DAPT group （17.9% vs 42.9%, P=0.042）. However, in the antiplatelet-treated patients, the incidences of PMI in these two groups were comparable（46.4% vs 51.7%, P=0.689）. Muhivariable logistic analy- sis performed in the overall study population showed that antiplatelet-treated[hazard ratio（HR ）=2.45, 95% confi- dence interval （CI） 1.09-5.52, P=0.030] was independently associated with the incidence of PMI. However, TAPT （versus DAPT） was not an independent protective factor of PMI. Conclusion The present study suggests that the adjunctive loading dose of Cilostazol can reduce the incidence of PCI related PMI in patients who are naive to antiplatelet agents. However, loading dose of DAPT is adequate for those who have been taking an- tiplatelets.