急性冠状动脉综合征患者抗血小板药物抵抗的影响因素分析

Analysis on influencing factors of antiplatelet drug resistance in patients with acute coronary syndrome

目的探索分析急性冠状动脉综合征患者抗血小板药物抵抗的临床影响因素,以帮助临床医师快速识别出可能存在抗血小板药物氯吡格雷抵抗的患者。方法本研究纳入2013年全年在中国医学科学院阜外医院行冠状动脉介入术的急性冠状动脉综合征患者。依据血栓弹力图二磷酸腺苷诱导的血小板纤维蛋白凝块强度(adenosine diphosphate-induced platelet-fibrin clot strength,MA_(ADP)),将入选患者分为药物抵抗组(MA_(ADP)>47 mm)与非药物抵抗组(MA_(ADP)≤47 mm)。利用临床基线数据,采用单因素和多因素Logistic回归分析筛选出与抗血小板药物氯吡格雷抵抗独立相关的影响因素。结果共2511例患者被纳入本研究,其中有781例(31.10%)患者存在氯吡格雷治疗下的药物抵抗。通过单因素分析及进一步的多因素Logistic回归分析,共筛选出肾功能异常(OR=3.08,95%CI:1.28~7.36)、女性(OR=2.86,95%CI:2.26~3.61)、合并糖尿病(OR=1.61,95%CI:1.33~1.95)、血小板增多(OR=1.55,95%CI:1.07~2.25)及质子泵抑制剂的使用(OR=1.25,95%CI:1.02~1.54)等5个与抗血小板药物抵抗有关的临床因素。结论肾功能异常、女性、合并糖尿病、血小板增多、使用质子泵抑制剂是患者发生抗血小板药物氯吡格雷抵抗的独立影响因素,在临床诊疗过程中需予以重点关注,从而指导个体化抗血小板治疗。

Objective To analyze the influencing factors of antiplatelet drug clopidogrel resistance in patients with acute coronary syndrome,so as to help clinicians quickly identify patients who may be resistant to antiplatelet therapy.Methods This study included patients with acute coronary syndrome who received coronary intervention and on dual antiplatelet at Fuwai Hospital throughout 2013.According to the results of thromboelastography(the result recorded as ADP-induced platelet-fibrin clot strength,MAADP)the selected patients were divided into resistance group(MA_(ADP)>47 mm)and non-resistance group(MA_(ADP)≤47 mm).Via clinical data,univariate and multivariate logistic regression analysis were used to screen out influencing factors independently related to clopidogrel treatment resistance.Results A total of 2511 patients were enrolled in the study,among them 781(31.10%)patients had clopidogrel treatment resistance.After univariate and further multivariate logistic regression analysis,five clinical factors were screened to be independently associated with resistance to antiplatelet therapy,namely reduced renal function(OR=3.08,95%CI:1.28-7.36);female(OR=2.86,95%CI:2.26-3.61);diabetes mellitus(OR=1.61,95%CI:1.33-1.95);elevated platelet count(OR=1.55,95%CI:1.07-2.25)and proton pump inhibitor use(OR=1.25,95%CI:1.02-1.54).Conclusion Reduced renal function,female,diabetes,elevated platelet count and the use of proton pump inhibitors are the independent influencing factors of antiplatelet drug clopidogrel resistance in patients with acute coronary syndrome,which need to be paid attention in the clinical treatment,thereby guiding individualized antiplatelet therapy.