血栓弹力图指导冠脉支架术后双重抗血小板治疗的研究

The study of dual antiplatelet therapy guided by thrombelastography in patients undergoing percutaneous coronary intervention

目的 测定行经皮冠状动脉介入术（PCI）患者的血小板功能,了解不同方案双重抗血小板治疗的MACE事件发生情况.方法 前瞻性地连续收入诊断为冠心病行择期PCI患者800例,根据术后血栓弹力图（TEG）检测结果将患者分为对照组（NPR＋常规抗血小板治疗）、标准治疗组（HPR＋常规抗血小板治疗）和强化治疗组（HPR＋强化抗血小板治疗）,随访1年MACE事件和TIMI出血事件发生率.结果 经TEG检测发现246例（30.75％）ADP抑制率＜40％即高血小板反应性（HPR）患者,随机分为标准治疗组（n=123）和强化治疗组（n=123）,其余为对照组（n=554）.两个HPR组与对照组（NPR组）相比,女性的比例明显居多（43.1％比22.4％,38.2％比22.4％,P＜0.01）,血糖（FBG）水平明显增高[（8.7±3.4）mmol/L比（6.9±2.9）mmol/L,（8.8±3.1）mmol/L比（6.9±2.9）mmol/L,P＜0.01],心肌酶水平明显增高[CK-Mb （2.7±0.7）ng/ml比（1.8±0.3）ng/ml和（2.8±0.4）ng/ml比（1.8±0.3）ng/ml,P＜0.01;TnI（0.8±0.3）ng/ml比（0.2±0.1）ng/ml和（0.9±0.4）ng/ml比（0.2士0.1）ng/ml,P＜0.01].标准治疗组MACE事件总发生率明显高于另外两组（P＜0.01）,而强化治疗组与对照组相比MACE事件发生率未见统计学差异（P＞0.05）.三组间总出血事件比较未见统计学差异（P均＞0.05）.结论 TEG检测快速、简单和准确.采用TEG对PCI术后患者进行常规检测,对HPR患者及时予以强化双重抗血小板治疗,可以有效减少临床缺血不良事件的发生.

Objective We sought to determine whether thrombelastography （TEG） was a good ex vivo platelet function measurement to facilitate risk stratification and personalized antiplatelet therapy in patients under- going PCI. Methods 800 patients undergoing elective PCI were included prospectively. They were divided into control group（NPR）, normal therapy group（HPR± conventional doze of Clopidogrel） and high-doze therapy group （HPR＋ double dozes of Clopidogrel）. The data of clinical characteristics, TEG parameters and MACE in I-year follow-up were collected. Results There were 246 patients （30.75%） defined as HPR whose ADP% was below 40%. They were divided randomly into therapy group （n= 123 ） and high-doze group （n= 123 ）, and the remainder was control group （n=554）. Compared to control group, there were more female gender （43.1% vs 22.4% and 38.2% vs 22.4%, P〈0.01）, higher level of fasting blood glucose [（8.7±3.4）mmol/L vs （6.9±2.9）mmol/L and （8.8±3.1）mmol/L vs （6.9±2.9）mmol/L, P〈0.01] and higher level of cardiac enzyme [CK-Mb （2.7±0.7） vs （ 1.8±0.3 ）ng/ml and （2.8±0.4）ng/ml vs （ 1.8±0.3 ）ng/ml, P〈0.01 ; TnI （0.8±0.3）ng/ml vs （0.2±0.1）ng/ml and （0.9±0.4）ng/ml vs （0.2±0.1）ng/ml, P〈0.01 ] in HPR groups. According to 1-year follow-up, the incidence of MACE was higher in standard therapy group than the others （P〈0.01）. However, the incidence of MACE in high-doze group was similar to control group （P〉0.05）. Total bleeding rate in all groups were similar （P〉0.05）. Con- clusion TEG is a rapid, simple and accurate measurement of the physical properties of a platelet-fibrin clot. TEG could guide the dual antiplatelet therapy in patients undergoing PCI and reduce the MACE incidence of HPR patients.