急性冠状动脉综合征患者PCI围术期肝素或替罗非班诱导血小板减少症的临床观察及干预分析

Clinical observation and intervention analysis of patients with acute coronary syndrome suffering from thrombocytopenia induced by heparin or tirofiban during perioperative period of PCI

目的:探讨急性冠状动脉综合征患者在经皮冠状动脉介入治疗(PCI)围术期发生肝素或替罗非班诱导血小板减少后的临床变化、干预效果及预后。方法:连续入选郑州大学第一附属医院2016年1月1日—2019年12月30日收治的118例急性冠状动脉综合征PCI围术期发生血小板减少的患者,根据纳入与排除,纳入78例患者,分为替罗非班诱导的血小板减少(TIT)组(48例)和肝素诱导的血小板减少(HIT)组(30例),比较最低血小板计数、血小板降低幅度、院内出血事件和随访期主要心脑血管不良事件(MACCE);根据TIT组和HIT组患者发生血小板减少后是否使用激素和(或)免疫球蛋白再分为治疗组和非治疗组两个亚组,比较亚组间血小板恢复时间和MACCE发生率。结果:TIT组最低血小板计数显著低于HIT组[18(4,60)×10^(9)/L∶57(32,84)×10^(9)/L,P=0.004],TIT组血小板降低幅度显著高于HIT组[90.74(74.18,98.30)%∶71.78(53.34,81.76)%,P=0.001];院内两组患者均未发生大出血事件;随访6个月内缺血事件HIT组明显高于TIT组(P=0.048);中位随访16个月,Kaplan-Meier生存分析显示两组远期MACCE发生率差异无统计学意义(Log-rank P=0.097);HIT组内治疗组和非治疗组血小板恢复时间、随访6个月内缺血事件和中位随访16个月MACCE发生率差异无统计学意义(P>0.05);TIT组内治疗组较非治疗组血小板恢复时间更长[5(1,6)d∶4(2,7)d,P=0.014],随访6个月内缺血事件和中位随访16个月MACCE发生率两个亚组比较差异无统计学意义(P>0.05)。结论:肝素和替罗非班均能导致严重血小板减少,替罗非班的血小板减少程度更重;与替罗非班相比,肝素明显增加患者近期缺血风险,二者对患者远期预后影响无明显差异;激素和(或)免疫球蛋白治疗对血小板恢复无改善作用,也不能改善患者的预后。

Objective:To explore the effects of thrombocytopenia induced by heparin or tirofiban on patients with acute coronary syndrome(ACS)during the perioperative period of PCI.Methods:There were 118 patients suffered from thrombocytopenia during perioperative period of PCI after ACS in this study.They came from January 1,2016 to December 30,2019 in the First Affiliated Hospital of Zhengzhou University.According to the inclusion and exclusion criteria,78 patients were divided into the tirofiban-induced thrombocytopenia(TIT)group(48 cases)and the heparin-induced thrombocytopenia(HIT)group(30 cases).Then we compared the lowest platelet count,percent change of thrombocytopenia,bleeding events during hospitalization,and major adverse cardiac and cerebrovascular events(MACCE)during follow-up.According to the application of hormone and/or immunoglobulin,each group was divided into treatment group and non-treatment group in order to compare platelet recovery time and MACCE incidence.Results:The lowest platelet count in TIT group was significantly lower than that in HIT group[18(4,60)×10^(9)/L:57(32,84)×10^(9)/L,P=0.004],and the percent of thrombocytopenia in TIT group was significantly higher than that in HIT group[90.74(74.18,98.30)%:71.78(53.34,81.76)%,P=0.001].There was no major bleeding event in both groups.The incidence of ischemic events within 6 months of follow-up was significantly higher in the HIT group(P=0.048).And during the median follow-up of 16 months,Kaplan-meier survival analysis showed that the incidences of long-term MACCE were similar in HIT group and TIT group(log-rank P=0.097).There were no significant differences in platelet recovery time,ischemic events within 6 months of follow-up,and MACCE incidence during the median follow-up of 16 months in two subgroups of HIT group(P>0.05).The platelet recovery time in the treatment subgroup of TIT group was longer[5(1,6)d:4(2,7)d,P=0.014].There was no statistical difference in the incidence of ischemic events within 6 months of follow-up and MACCE incidence during the median follow-up of 16 months in two subgroups of TIT group(P>0.05).Conclusion:Both HIT and TIT can cause severe thrombocytopenia,and the degree of thrombocytopenia of TIT is worse.Compared with TIT,HIT can significantly increase the risk of short-term ischemia.There is no difference in the long-term prognosis of the HIT and TIT patients.Hormone and/or immunoglobulin therapy cannot improve platelet recovery and patient outcomes.