血栓弹力图对急性非心源性脑梗死患者抗血小板聚集治疗的临床价值

Clinical value of thrombelastography in antiplatelet therapy for acute non-cardioembolic cerebral infarction

目的 探讨血栓弹力图(TEG)对急性非心源性脑梗死患者抗血小板聚集治疗的临床价值.方法 采用前瞻性研究,连续选取2016年6月~12月徐州医科大学第二附属医院神经内科住院治疗的148名急性非心源性脑梗死患者,采用TOAST病因分型排除心源性栓塞型后随机分成TEG组和对照组,每组74例.入院后采用ESSEN卒中风险评分量表(ESRS)评分,ESRS评分≥3分口服氯吡格雷,ESRS评分<3分口服阿司匹林,TEG组连续服用1周后行TEG检测确定血小板抑制率,根据抑制率是否达标来调整用药方案,对照组不给予TEG检测.随访至发病后6个月,采用改良Rankin量表(mRS)评分评估临床转归,并观察和比较随访期间两组患者的血栓栓塞事件、出血事件发生率及有无死亡事件.结果 随访结束时,TEG组失访4例,对照组失访5例.随访期间,TEG组有7.14%(5/70)发生血栓栓塞事件,有2.86%(2/70)发生出血,均为轻微出血,未见严重大出血及死亡事件;对照组有24.64%(17/69)发生血栓栓塞事件,有15.94%(11/69)发生出血,其中7例轻微出血,2例消化道大出血, 1例颅内大出血导致死亡.TEG组血栓栓塞事件及出血事件发生率低于对照组(7.14%比24.64%,χ2=7.983,P=0.005;2.86%比15.94%,P=0.009);TEG组mRS评分低于对照组(1.65±0.48比2.82±0.73,t=2.15,P=0.041).结论 根据TEG结果选择敏感抗血小板聚集药物能改善急性非心源性脑梗死患者临床预后,降低血栓栓塞事件和出血事件发生率,值得在临床工作中推广.

Objective To investigate the clinical value of thrombelastogram(TEG)in antiplatelet therapy for acute non-cardioembolic cerebral infarction. Methods A prospective study was conducted in 148 consecutive patients with acute non-cardioembolic cerebral infarction,who stayed in our hospital between June 2016 and December 2016. The patients were excluded of having cardioembolic cerebral infarction by using TOAST etiologic classification,and were then randomly divided into TEG group and control group(n=74 each). After admission,the subjects were assessed for ESSEN Stroke Risk Rating Scale(ESRS). Those with an ESRS score ≥ 3 were given oral clopidogrel,and those with an ESRS score < 3 were treated with aspirin. After one week of continuous administration,TEG group underwent TEG to determine the platelet inhibition rate,and the dosage regimen was adjusted according to whether or not the desired inhibition rate was reached. The control group did not undergo TEG. Follow-up continued up to 6 months after onset, Clinical outcomes were assessed using the modified Rankin scale(mRS). The incidence of thromboembolic events,bleeding events,and deaths during the follow-up were noted and compared between the two groups. Results At the end of follow-up,4 patients in the TEG group and 5 in the control group were lost. During the follow-up,the TEG group was noted of thromboembolism in 7.14%(5/70)and bleeding in 2.86%(2/70) of the patients. The bleeding was mild in all patients. No severe/massive bleeding or death was noted. In contrast,thromboembolic events were noted in 24.64%(17/69)and bleeding in 15.94%(11/69)of the patients in the control group. The bleeding was mild in 7 patients,but included massive gastrointestinal bleeding in 2 patients and massive intracranial hemorrhage in a death case. The incidence rates of thromboembolic events and bleeding were lower in the TEG group than those in the control group(7.14% vs 24.64%,χ2=7.983,P=0.005;2.86% vs 15.94%,P=0.009). The mRS score in the TEG group was lower than that in the control group(1.65±0.48 vs 2.82±0.73,t=2.15,P=0.041). Conclusion Selecting sensitive anti-platelet agents based on TEG results may improve the clinical prognosis of patients with acute cardioembolic cerebral infarction and may reduce the incidence of thromboembolic and bleeding events,and therefore is worthwhile of widespread use in clinical practices.