氯吡格雷低反应的老年急性冠状动脉综合征患者换用替格瑞洛后的疗效及出血危险因素

Efficacy and Bleeding Risks of Ticagrelor Replacement for Treating Elderly Acute Coronary Syndrome Patients With Low Response to Clopidogrel

目的:观察替格瑞洛对氯吡格雷低反应的择期经皮冠状动脉介入治疗(PCI)后老年急性冠状动脉综合征(ACS)患者的疗效,评估治疗过程中出血并发症的危险因素。方法:入选2014-01至2017-01期间945例年龄≥65岁的ACS患者,患者入院后均给予阿司匹林及氯吡格雷双联抗血小板治疗(DAPT)。用血栓弹力图分别测定DAPT≥5 d后患者的血小板抑制率,根据血小板抑制率筛选出氯吡格雷低反应患者293例,这些患者全部换用替格瑞洛,调整DAPT方案≥5 d后再次检测血小板抑制率,对比患者替格瑞洛更换前后血小板抑制率的变化情况(替格瑞洛组);其余652例患者继续应用氯吡格雷(氯吡格雷组)。采用TIMI出血评估标准,随访3个月,比较氯吡格雷组和替格瑞洛组的出血发生率,并应用Logistic回归分析老年ACS患者应用替格瑞洛发生出血并发症的危险因素。结果:氯吡格雷低反应的293例老年ACS患者换用替格瑞洛后5~7 d、8~14 d、15~90 d,血小板抑制率分别为(51.70±42.90)%、(48.99±41.85)%、(55.08±25.70)%,均显著高于其应用氯吡格雷时的血小板抑制率(14.50±24.15)%,差异均有统计学意义(P均<0.05)。替格瑞洛组大出血发生率与氯吡格雷组相比,差异无统计学意义(P=0.96)。Logistic多因素分析提示,女性(OR=4.329,P=0.000)、低体重(OR=0.817,P=0.039)、空腹血糖升高(OR=1.251,P=0.028)是老年ACS患者应用替格瑞洛发生出血并发症的独立危险因素。结论:与应用氯吡格雷相比,老年ACS患者应用替格瑞洛能更快、更有效地抑制血小板聚集,且不增加大出血的发生率,安全性高。女性、低体重、空腹血糖升高是择期PCI后老年ACS患者应用替格瑞洛发生出血并发症的独立危险因素。

Objective：To observe the efficacy of ticagrelor for treating elderly acute coronary syndrome（ACS） patients with elective PCI and having low response to clopidogrel;to explore the bleeding risks induced by ticagrelor replacement.Methods：A total of 945 ACS patients ≥ 65 years treated in our hospital from 2014-01 to 2017-01 were enrolled.All patients received aspirin and clopidogrel dual antiplatelet therapy（DAPT）,thrombelastography（TEG） was used to detect platelet inhibition rate when DAPT ≥ 5 days.Based on platelet inhibition rate,the patients were divided into 2 groups：Ticagrelor replacement group,n=293 patients with low response to clopidogrel and switched to ticagrelor treatment,when adjusted DAPT ≥ 5 days,platelet inhibition rate was rechecked to compare the changes;Clopidogrel group,the patients were continuously treated by the same medication,n=652.The patients were followed-up for 3 months,bleeding events were evaluated by TIMI criteria and compared between 2 groups.Risk factors of ticagrelor induced bleeding were assessed by multivariate Logistic regression analysis.Results：Platelet inhibition rates in Ticagrelor replacement group were（51.70±42.90） %,（48.99±41.85） % and（55.08±25.70） % at（5-7） d,（8-14） d and（15-90） d ticagrelor treatment,which were higher than previous clopidogrel treatment（14.50±24.15） %,all P〈0.05.The incidences of severe bleeding events were similar between 2 groups,P=0.96.Multivariate Logistic regression analysis presented that female（OR=4.329,P=0.000）,low body weight（OR=0.817,P=0.039） and elevated fasting blood glucose（OR=1.251,P =0.028） were the independent risk factors for bleeding complication in ticagrelor treated elderly ACS patients.Conclusion：Compared with clopidogrel,ticagrelor may faster and more effectively inhibit platelet aggregation without increasing severe bleeding;female,low body weight and elevated fasting blood glucose were the independent risk factors for bleeding complication in ticagrelor treated elderly ACS patients with elective PCI.