经皮冠状动脉介入治疗患者抗血小板药物抵抗的相关因素分析

Analysis of the factors related to antiplatelet resistance in patients with acute coronary syndrome undergoing percutaneous coronary intervention

目的分析经皮冠状动脉介入治疗(PCI)后的急性冠脉综合征(ACS)患者抗血小板药物治疗抵抗的发生率及临床危险因素。方法 381例行PCI治疗的ACS患者,根据血栓弹力图(TEG)血小板聚集抑制率(PAI)的结果将患者分组。ADP诱导的PAI(ADP-PAI)<30%为氯吡格雷抵抗(CR);AA诱导的PAI(AA-PAI)<50%为阿司匹林抵抗(AR)。对所有入组患者临床资料及常规生化指标进行回顾性分析。结果所有381例ACS患者均给予双重抗血小板治疗,其中72例(18.9%)为CR,30例(7.9%)为AR。多元回归分析结果显示,HDL和FBG与ADP-PAI呈显著负相关(r2=20.3%,P<0.05);糖尿病病程和hs-CRP与AA-PAI密切相关(r2=21.8%,P<0.05)。研究人群中,13例(3.4%)为双重抵抗(DR),76例(19.95%)是CR或AR的单一抵抗(SR)。糖尿病病程、FBG及Hb A1c在DR组显著高于SR及反应正常组(P<0.05)。对年龄及性别的研究显示,ADP-PAI在老年人及非老年人中无显著性差异,无论是男性还是女性(P>0.05);而老年女性的AA-PAI显著低于非老年女性(P<0.01)。老年女性较同龄男性ADP-PAI更低(P<0.05);而年轻女性AA-PAI较同龄男性明显升高(P<0.01)。结论 PCI术后的ACS患者,FBG及HDL升高是CR的高危因素;糖尿病病程长及高hsCRP水平的患者更容易发生AR。糖尿病病程长、血糖控制不佳患者更易发生2种抗血小板药物联合抵抗,这种患者相当危险。老年女性CR风险高于同龄男性,而年轻男性及老年女性发生AR的风险偏高。了解抗血小板治疗抵抗高危因素,对于高危患者,早期筛查、早期诊断、及时改变治疗方案可能是预防PCI术后血栓形成并发症的有效方法之一。

Objective To evaluate the prevalence and clinical risk factors of antiplatelet drug resistance in patients with acute coronary syndrome （ACS） undergoing pereutaneous coronary intervention （PCI）. Methods Anti- platelet drug resistance was assessed by thrombelastograph （TEG） in 381 ACS patients undergoing PCI who received combined treatment of aspirin and clopidogrel. Clopidogrel reisistance （CR） was defined as ADP-induced platelet ag- gregation inhibition （ADP-PAI） rate 〈 30% , whereas aspirin resistance （AR） was defined as AA-induced PAI （AA- PAI） rate 〈 50%. The medical records of these patients were retrospectively reviewed, and demographic characteris- tics,medical history and laboratory results were recorded. Results Among 381 patients included in this study,there were 72 cases（ 18.9% ） of CR and 30 cases （7.9%） of AR. In a multivariable linear regression model ,HDL and FBG were inversely related to ADP-PAI （r2 = 20. 3 %, P 〈 0. 05 ）, while hs-CRP and duration of diabetes mellitus were inversely related to AA-PAI （ r2 = 21.8% ,P 〈 0. 05 ）. In all the patients, 13 cases （ 3.4% ） were dural resistance （DR） which had both CR and AR,76 cases（ 19.95% ） were single resistance （SR） which were defined as either CR or AR, and 292 cases were normal responder （NR）. The patients with DR had a significantly longer DM history, higher FBG and HbA1 c levels than the other two groups. Young （age 〈 60 years） and elderly （age ≥ 60 years ） patients had similar ADP-PAI, be it male or female （ P 〉 0.05 ）. However, AA-PAI in elderly women was significantly lower than that of young women （ P 〈 0. 01 ）. ADP-PAI in elderly women was lower than the men at the same age （ P 〈 0. 05 ） ; on the contrary, AA-PAI in young women was significantly higher than the men at the same age（ P 〈 0. 01 ）. Conclusion Af- ter PC! in patients with ACS ,high level of FBG and HDL are risk factors for CR,and long DM history and high level of hs-CRP are more likely to be AR. The patients with long DM history and poor glycemic control are more likely to become dural biochemical nonresponders. In elderly patients, women have higher risk of CR, while in young patients, male have higher risk of AR. The antiplatelet drug resistance of patients with these risk factors should be watched. Early screening and early diagnosis may avoid high risk of thrombotic complications after PCI.