三种抗血小板治疗策略对经皮冠状动脉介入术后高龄急性冠状动脉综合征患者临床预后的影响

Clinical prognosis effects of individualized antiplatelet therapy on elderly acute coronary syndrome patients after percutaneous coronary intervention treatment

目的:比较不同抗血小板药物对经皮冠状动脉介入(PCI)术后高龄急性冠状动脉综合征(ACS)患者的安全性和有效性。方法:筛选2018年1月至2021年1月于石家庄市人民医院心内科住院的高龄(≥75岁),且行PCI治疗的ACS患者750例。根据应用不同抗血小板药物将患者分为三组(阿司匹林+氯吡格雷组1组)615例、阿司匹林+替格瑞洛组(2组)79例、阿司匹林+氯吡格雷+西洛他唑组(3组)56例,三组患者均进行随访,平均随访时间(8.88±5.95)个月,统计不良事件(全因死亡、非致死性心肌梗死、卒中或靶血管血运重建)发生率及出血风险。结果:对所有符合条件的入选患者(n=750)进行临床随访,其中39例患者失访,失访率5.2%,711例患者有效,其中1组581例(81.7%),2组75例(10.5%),3组55例(7.7%),共有64例患者(9.0%)出现MACE事件,其中1组59例(10.2%)2组2例(2.7%)3组3例(5.5%)。替格瑞洛可降低非致死性心肌梗死(OR=0.047,95%CI:0.006~0.392,P=0.005)、卒中(OR=0.087,95%CI:0.010~0.743,P=0.026)、靶血管血运重建(OR=0.088,95%CI:0.010~0.754,P=0.027)的发生率。西洛他唑降低非致死性心肌梗死(OR=0.070,95%CI:0.009~0.571,P=0.013)及靶血管血运重建(OR=0.075,95%CI:0.009~0.632,P=0.017)的发生率,然而替格瑞洛组和西洛他唑组在降低MACE发生率差异无统计学意义(P均>0.05)。共有26例患者发生出血(3.7%,包括严重出血、小出血及轻微出血)其中1组15例(2.6%)2组7例(9.3%)3组4例(7.2%)。替格瑞洛组轻微出血的发生率较标准组(1组)明显增加(OR=4.105,95%CI:1.471~11.455,P=0.007),而西洛他唑组不增加出血风险(P=0.751)。结论:在目前的医疗环境中,替格瑞洛和西洛他唑的处方率相对阿司匹林+氯吡格雷的标准治疗并不高,但可改善临床预后,尤其西洛他唑不增加出血风险,在PCI术后的高龄ACS患者中应用安全。

Objective:To compare the safety and efficacy of contemporary different antiplatelet drugs on elder acute coronary syndrome(ACS)patients following percutaneous coronary intervention(PCI).Methods:Elderly(≥75 year)ACS patients(n=750)undergone PCI were chosen from cardiovascular medicine department of Shijiazhuang people′s hospital from Jan 2018 to Jan 2021.Patients were divided into three groups based on different antiplatelet drugs:Aspirin+clopidogrel(group 1,n=615),Aspirin+ticagrelor(group 2,n=79),and Aspirin+clopidogrel+cilostazol(group 3,n=56)groups.During a median follow-up of(8.88±5.95)months,The major adverse cardiac events(MACEs:cardiovascular death,nonfatal MI,stroke or target vessel revascularization)and the risk of any bleeding were observed and compared.Result:All eligible patients(n=750)were followed up.Among them,39 patients were lost to follow-up.The rate of lost visits was 5.2%.711 patients were effective.The prescription rates of the three groups were 81.7%,10.5%and 7.7%respectively.MACEs occurred in 64 patients(9.0%),with 59(10.2%),2(2.7%),and 3(5.5%)patients in clopidogrel,ticagrelor,cilostazol respectively(median follow-up,8.88±5.95 months).ticagrelor can reduce the incidence of non-fatal myocardial infarction(OR=0.047,95%CI:0.006-0.392,P=0.005),stroke(OR=0.087,95%CI:0.010-0.743,P=0.026),targetvessel revascularization(OR=0.088,95%CI:0.010-0.754,P=0.027).Cilostazol reduced the incidence of non-fatal myocardial infarction(OR=0.070,95%CI:0.009-0.571,P=0.013)and target vessel revascularization(OR=0.075,95%CI:0.009-0.632,P=0.017);the difference between ticagrelor and cilostazol for fewer MACEs was nonsignificant(P>0.05).Bleeding,including severe,minor and slight ones,occurred in 26(3.7%)patients,with 15(2.6%),7(9.3%),and 4(7.2%)patients using clopidogrel ticagrelor and cilostazol.There is significantly higher incidence in ticagrelor(OR=4.105,95%CI:1.471-11.455,P=0.007)users than in clopidogrel users.While cilostazol did not increase the risk of bleeding(P=0.751).Conclusions:In current medical care environment,for real-world ACS patients following PCI,ticagrelor and cilostazol were not prescribed at higher rates than clopidogrel,but were found to improve clinical outcomes,in particular,cilostazol does not increase the risk of bleeding and is safe for elderly patients with ACS after PCI.