血脂对非ST段抬高型急性冠脉综合征患者经皮冠状动脉介入术后双联抗血小板治疗残余血小板反应性的影响

Impact of serum lipid level on residual platelet reactivity in patients with non-ST elevation acute coronary syndrome receiving dual anti-platelet therapy after percutaneous coronary intervention

目的探讨植入药物洗脱支架的非ST段抬高型急性冠脉综合征(non-ST elevation acute coronary syndrome,NSTE-ACS)患者接受阿司匹林+氯吡格雷双抗治疗后,血脂水平对残余血小板反应性影响。方法前瞻性招募复旦大学附属中山医院心内科2017年2月至2017年12月诊治的NSTE-ACS患者335例。所有患者行冠脉造影及支架植入术,术前给予负荷剂量氯吡格雷300 mg、阿司匹林300 mg,术后维持剂量为氯吡格雷75 mg、阿司匹林100 mg。术后第3天进行血栓弹力图检测,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,MAADP)大于47 mm提示高残余血小板反应(high-residual platelet reactivity,HRPR)。HRPR组患者71例,non-HRPR组264例。比较两组患者间人口学特征及实验室检查指标。采用Pearson相关分析、逐步回归模型分析血脂水平对患者残余血小板反应性的影响。Kaplan-Meier生存曲线评估不同血脂水平的HRPR组与non-HRPR组患者的预后。结果Pearson相关分析显示,总胆固醇(r=0.256,P<0.001)和低密度脂蛋白胆固醇(low-density lipoprotein cholesterol,LDL-C;r=0.284,P<0.001)均与MAADP正相关。多因素logistic回归分析显示,LDL-C是HRPR发生的独立危险因素(OR=2.209,95%CI 1.591~3.066,P<0.001)。生存曲线结果显示,HRPR合并LDL-C≥2.6 mmol/L患者1年内再发缺血性事件的比例较高。结论NSTE-ACS患者支架植入术后,LDL-C水平升高可增强血小板活性,进而导致缺血事件增加,提示对于此类患者,应延长双抗治疗时间。

Objective To explore the impact of lipid level on the platelet function of patients with non-ST elevation acute coronary syndrome(NSTE-ACS)receiving aspirin and clopidogrel after drug-eluting stents implantation.Methods A total of 335 NSTE-ACS patients underwent percutaneous coronary intervention(PCI)in Zhongshan Hospital,Fudan University from February 2017 to December 2017 were included prospectively.All patients took orally loading dose of aspirin 300 mg and clopidogrel 300 mg before PCI and maintenance dose of aspirin 100 mg and clopidogrel 75 mg after PCI.Thrombelastography were performed on the third day after PCI,and adenosine diphosphate-induced platelet-fibrin clot strength(MAADP)>47 mm was defined as a highresidual platelet reactivity(HRPR).There were 71 patients and 264 patients in the HRPR and non-HRPR groups,respectively.The impact of lipid indexes on platelet reactivity was analyzed by Pearson correlation analysis and multivariate analysis.Kaplan-Meiern survival curve was used to compare ischemic major adverse cardiac event rates among HRPR and non-HRPR groups with different lipid levels.Results Pearson correlation analysis showed that both total cholesterol(r=0.256,P<0.001)and low-density lipoprotein cholesterol(LDL-C)levels(r=0.284,P<0.001)were positively correlated with MAADP.The multivariate regression analysis showed that LDL-C was the independent risk factor contributing to HRPR(OR=2.209,95%CI 1.591-3.066,P<0.001).The occurrence of ischemic major adverse cardiac events in HRPR with LDL-C≥2.6 mmol/L patients was significantly higher(P<0.05).Conclusions For NSTE-ACS patients receiving dual anti-platelet therapy after PCI,LDL-C elevating may result in HRPR and increased ischemic events,which indicates that the dual anti-platelet therapy should be prolonged.