Effects of high-dose glucose-insulin-potassium on acute coronary syndrome patients receiving reperfusion therapy:a meta-analysis

BACKGROUND:This meta-analysis aimed to assess the efficacy of high-dose glucose-insulinpotassium(GIK) therapy on clinical outcomes in acute coronary syndrome(ACS) patients receiving reperfusion therapy.METHODS:We searched the PubMed,Web of Science,MEDLINE,Embase,and Cochrane Library databases from inception to April 26,2022,for randomized controlled trials(RCTs) that compared high-dose GIK and placebos in ACS patients receiving reperfusion therapy.The primary endpoint was major adverse cardiovascular events(MACEs).RESULTS:Eleven RCTs with 884 patients were ultimately included.Compared with placebos,high-dose GIK markedly reduced MACEs(risk ratio [RR] 0.57,95% confidence interval [95% CI]:0.35 to 0.94,P=0.03) and the risk of heart failure(RR 0.48,95% CI:0.25 to 0.95,P=0.04) and improved the left ventricular ejection fraction(LVEF)(mean difference [MD] 2.12,95% CI:0.40 to 3.92,P=0.02) at 6 months.However,no difference was observed in all-cause mortality at 30 d or 1 year.Additionally,high-dose GIK was significantly associated with increased incidences of phlebitis(RR 4.78,95% CI:1.36 to 16.76,P=0.01),hyperglycemia(RR 9.06,95% CI:1.74 to 47.29,P=0.009) and hypoglycemia(RR 6.50,95% CI:1.28 to 33.01,P=0.02) but not reinfarction,hyperkalemia or secondary reperfusion.In terms of oxidative stress-lowering function,high-dose GIK markedly reduced superoxide dismutase(SOD) activity but not glutathione peroxidase(GSH-Px) or catalase(CAT) activity.CONCLUSION:Patients with ACS receiving reperfusion therapy exhibited a reduction in MACEs and good oxidative stress-lowering eflcacy in response to high-dose GIK.Moreover,with a higher incidence of complications such as phlebitis,hyperglycemia,and hypoglycemia.Furthermore,there were no observed survival benefits associated with high-dose GIK.More trials with long-term follow-up are still needed.

Efficacy and safety of individually tailored antiplatelet therapy in patients with acute coronary syndrome after coronary stenting： a single center, randomized, feasibility study

Background Low responsiveness to clopidogrel （LRC） is associated with increased risk of ischemic events. This study was aimed to explore the feasibility of tailored antiplatelet therapy according to the responsiveness to clopidogrel. Methods A total of 305 clopidogrel naive patients with acute coronary syndromes （ACS） undergoing coronary stenting were randomly assigned to receive standard （n = 151） or tailored （n = 154） antiplatelet therapy. The ADP-induced platelet aggregation tests by light transmission aggregometry were performed to identify LRC patients assigned to the tailored group. The standard antiplatelet regimen was dual antiplatelet therapy with aspirin and clopidogrel. The tailored antiplatelet therapy was standard regimen for non-LRC patients and an additional 6-month cilostazol treatment for LRC patients. The primary efficacy outcome was the composite of cardiovascular death, myocardial infarction or stroke at one year. Results LCR was present in 26.6% （41/154） of patients in the tailored group. The percentage platelet aggregation for LCR patients was significantly decreased at three days after adjunctive cilostazol treatment （77.5% ± 12.1% vs. 64.5% ± 12.1%, P 〈 0.001）. At one year follow-up, a non-significant 37% relative risk reduction of primary events were observed in the tailored group as compared to the standard group （5.8% vs. 9.3%, P = 0.257）. There were no differences in the rates of stent thrombosis and hemorrhagic events between the two groups. Conclusions Tailored antiplatelet therapy for ACS patients after coronary stenting according to responsiveness to clopidogrel is feasible. However, its efficacy and safety need further confirmation by clinical trials with larger sample sizes.

Is dual therapy the correct strategy in frail elderly patients with atrial fibrillation and acute coronary syndrome?

Atrial fibrillation(AF)is a very common arrhythmia in clinical practice.Its incidence and prevalence are age-related and are growing in the last years.Age is a risk factor also for coronary artery disease(CAD),and with the evolution of preventive care,the first event(acute coronary syndrome(ACS)or percutaneous coronary intervention(PCI))takes place at a later age.If elderly patients with AF and CAD undergo ACS or PCI,they have indication to assume triple therapy.Triple therapy(oral anticoagulation(OAC)plus dual antiplatelet therapy(DAPT))exposes patients to high bleeding risk.In the last 10 years,several clinical trials have tested dual therapy(OAC plus single antiplatelet therapy)in AF patients who undergo ACS or elective PCI.WOEST trial has tested warfarin+clopidogrel against triple therapy.PIONEER AF-PCI trial has tested low-dose rivaroxaban+P2Y12 inhibitor or very low-dose rivaroxaban+DAPT against standard triple therapy with warfarin.RE-DUAL PCI trial has tested two doses of dabigatran+P2Y12 inhibitor against standard triple therapy with Warfarin.AUGUSTUS trial has tested apixaban against warfarin both in dual therapy with P2Y12 inhibitor and in triple therapy with a P2Y12 inhibitor and aspirin.ENTRUST-AF PCI,last published study,has tested edoxaban+P2Y12 inhibitor against triple therapy.All these trials show dual therapy reduces significantly bleeding risk than triple therapy.In this paper,we analyze these clinical trials to understand if dual therapy results can be applied to elderly patients and what is probably the better approach in elderly AF patients undergo to ACS or PCI.

Antiplatelet therapy in very elderly and comorbid patients with acute coronary syndromes

With population ageing and rise of life expectancy,a progressively increasing proportion of patients presenting with an acute coronary syndrome(ACS)are older adults,including those at extreme chronological age.Increasing amounts of data,including randomized clinical trials,have shown that the benefits of an early revascularization are maintained also at very old age,resulting in improved outcome after an acute coronary event.On the contrary,the optimal antiplatelet therapy(APT)remains unclear in these patients,because of both safety and efficacy concerns.Indeed,age-related multiple organ dysfunction and high prevalence of comorbidities may on the one hand reduce the therapeutic effects of administered drugs;on the other hand,it leads to increased vulnerability to drug toxicity and side effects.Therefore,management of APT is particularly challenging in elderly patients because of higher risk of both ischemic and bleeding events.The aim of the present paper is to review the current evidence,gaps in knowledge and ongoing research regarding APT in the setting of an ACS in elderly and very elderly patients,and in those with significant comorbidities including chronic kidney disease,diabetes mellitus and frailty.

Impact of triple antithrombotic therapy in patients with acute coronary syndrome undergoing percutaneous coronary intervention in real-world practice

Objective The optimal antithrombotic regimen for patients on oral anticoagulation （OAC） after acute coronary syndrome （ACS） and percutaneous coronary intervention （PCI） remains debated. This study sought to evaluate the efficacy and safety of OAC plus clopidogrel with or without aspirin in a real-world setting. Methods We retrospectively analyzed data from an international, multi-center registry be- tween 2003 and 2014 （n = 15,401）. Patients with ACS and receiving OAC after PCI were screened. The composite primary endpoint was 1-year all-cause death, re-infarction, or severe bleeding. Results The final analysis enrolled 642 patients including 62 patients （9.7%） with OAC and clopidogrel （dual therapy）, and 580 patients （90.3%） with the combination of aspirin, OAC and clopidogrel （triple therapy）. Pa- tients on triple therapy were more often female and were more likely to have comorbidities. There was no significant difference regarding the primary end point between dual therapy with triple therapy patients [17.74% vs. 17.24%; unadjusted hazard ratio （HR）： 1.035; 95% confi- dence interval （CI）： 0.556-1.929; adjusted HR： 1.026; 95% CI： 0.544-1.937]. However, the re-infarction rate was significantly higher in dual therapy than triple therapy patients （14.52% vs. 5.34%; unadjusted HR： 2.807; 95% CI： 1.329-5.928; adjusted HR： 2.333; 95% CI： 1.078-5.047）. In addition, there was no difference between two regimes in all-cause death and severe bleeding. Conclusions In real-life patients with ACS following PCI and with an indication of OAC, triple therapy was not associated with an increased rate of adverse out- comes compared to dual therapy. Moreover, it decreased risk of re-infarction and did not increase risk of severe bleeding.

Prolonged dual antiplatelet therapy after drug-eluting stent implantation improves long-term prognosis for acute coronary syndrome:five-year results from a large cohort study

BACKGROUND:To investigate the most appropriate dual antiplatelet therapy(DAPT)duration for patients with acute coronary syndrome(ACS)after drug-eluting stent(DES)implantation in the largest cardiovascular center of China.METHODS:We enrolled 5,187 consecutive patients with ACS who received DES from January to December 2013.Patients were divided into four groups based on DAPT duration:standard DAPT group(11-13 months,n=1,568)and prolonged DAPT groups(13-18 months[n=308],18-24 months[n=2,125],and>24 months[n=1,186]).Baseline characteristics and 5-year clinical outcomes were recorded.RESULTS:Baseline characteristics were similar across the four groups.Among the four groups,those with prolonged DAPT(18-24 months)had the lowest incidence of major adverse cardiovascular and cerebrovascular events(MACCEs)(14.1%vs.11.7%vs.9.6%vs.24.2%,P<0.001),all-cause death(4.8%vs.3.9%vs.2.1%vs.2.6%,P<0.001),cardiac death(3.1%vs.2.6%vs.1.4%vs.1.9%,P=0.004),and myocardial infarction(MI)(3.8%vs.4.2%vs.2.5%vs.5.8%,P<0.001).The incidence of bleeding was not different among the four groups(9.9%vs.9.4%vs.11.0%vs.9.4%,P=0.449).Cox multivariable analysis showed that prolonged DAPT(18-24 months)was an independent protective factor for MACCEs(hazard ratio[HR]0.802,95%confidence interval[CI]0.729-0.882,P<0.001),all-cause death(HR 0.660,95%CI 0.547-0.795,P<0.001),cardiac death(HR 0.663,95%CI 0.526-0.835,P<0.001),MI(HR 0.796,95%CI 0.662-0.957,P=0.015),and target vessel revascularization(HR 0.867,95%CI 0.755-0.996,P=0.044).Subgroup analysis for high bleeding risk showed that prolonged DAPT remained an independent protective factor for all-cause death and MACCEs.CONCLUSION:For patients with ACS after DES,appropriately prolonging the DAPT duration may be associated with a reduced risk of adverse ischemic events without increasing the bleeding risk.

Risk Factors for Gastrointestinal Injuries in Acute Coronary Syndrome Patients with Double Antiplatelet Therapy in One-Year Follow-Up

Background: The goal is to determine the incidence of symptomatic gastrointestinal (GI) injuries in acute coronary syndrome (ACS) patients receiving double antiplatelet therapy (DAPT). The risk factors for serious GI complications are also evaluated. Methods: 603 eligible patients from the Department of Cardiology at Zhongda Hospital between January 2014 and August 2015 were enrolled and the occurrence of GI injuries within one year assessed. The risk factors for serious GI complications were identified using cox regression analysis. Results: After one-year follow-up, 108 (17.9%) out of 603 patients developed symptomatic GI injuries: 22 (3.65%) with serious GI complications and 86 (14.2%) with GI symptoms. Drinking habit (95% CI: 1.512 - 8.796;P = 0.004) and previous peptic injury (95% CI: 2.307 - 18.080;P = 0.001) are independent predictors of serious GI complications, while proton pump inhibitor (PPI) was protective (95% CI: 0.120 - 0.699;P = 0.006) per cox regression analysis. Additionally, GI injuries of both serious GI complications and GI symptoms peaked in the first three months. Conclusions: Symptomatic GI injuries were relatively common in ACS patients with DAPT, especially in the first three months. Previous peptic injury and drinking habit were significant independent risk factors for serious GI complications, while PPI played a protective role in ACS with DAPT.

Relationship between Traditional Chinese Medicine Syndrome Type and Coronary Arteriography of Acute Coronary Syndrome

Objective: To explore the relationship of Traditional Chinese Medicine (TCM) Syndrome type and coronary arteriography (CAG) with respect to the number and degree of stenosed branches of coronary artery (CA) and ACC/AHA stage of acute coronary syndrome (ACS), to provide an objective evidence for TCM Syndrome typing on ACS Methods: Ninety patients of ACS with their TCM Syndrome typing and CAG successfully conducted were enrolled in this study. They were classified into 3 Syndrome types, the blood stasis type (type I ), the phlegm stagnant with blood stasis type (type II ),and the endogenous collateral Wind type (type III) The scores of the number and severity of the stenosis branch of CA and ACC/AHA lesion stage in different Syndrome types were calculated respectively and analysed statistically by Ridit analysis. Results: The number of stenosed branches increased gradually with the Syndrome type changing from I -II-III, compared the type III with the other two types(P<0. 01). The severity of stenosis in type I and II were similar, but that of Type III, much aggravated was significantly different from that in the former two (P<0. 01) . The ACC/AHA stage of coronary lesion tended to be more complex as the Syndrome type changed, patients of TCM type I and II had mostly lesion of stage A or Bl , while lesion in majority of patients of type III belonged to stage B2 or C, comparison between the three types showed significant difference (P<0.01). Conclusion: Most ACS patients of TCM Syndrome type III with tri-branch, severe stenosed coronary arteries, belong to the complex ACC/AHA stage of B2 and C.

Fondaparinux:A cornerstone drug in acute coronary syndromes

In acute coronary syndrome(ACS),the use of anticoagulants in conjunction with antiplatelet agents in the acute phase has resulted in reduced ischemic events and is more effective than either class of drug used alone.Though parenteral anticoagulation is essential at the time of diagnosis,a balance must be made between ischemic benefit and the increased risk of bleeding when prescribing anticoagulants.Adverse events associated with anticoagulants,such as heparin-induced thrombocytopenia,bleeding problems,and the need for close monitoring of anticoagulant activity,have contributed to finding agents that reduce these limitations.Studies like the Organization to Assess Strategies in Ischemic Syndromes 5 and 6 and their meta-analysis have proven the efficacy of Fondaparinux over the entire ACS spectrum.The convenience of administration(once daily),lack of monitoring,reduction in mortality,and better safety profile make Fondaparinux a simple and effective anti-coagulant for the management of ACS.

In-hospital outcome of elderly patients with acute coronary syndromes treated with platelet glycoproteinⅡb/Ⅲa blockers

Background and objective The safety of intravenous glycoproteinⅡb/Ⅲa inhibitors (GPI) in elderly patients admitted with acute coronary syndrome (ACS) has not yet been established. The purpose of this study was to evaluate the safety of GPI in elderly patients with ACS. Methods Ninety consecutive patients≥70 years of age admitted to a county hospital between 1999-2004 were included. All patients had typical ACS symptoms along with high-risk markers. Results There was no difference in the TIMI risk score between patients who received GPI (n=47) and those who did not (n=43). Patients who received GPI had a lower creatinine clearance (40 cc/min vs. 47cc/min, p= 0.04). Patients who received GPI had a lower incidence of death, reinfarction or major bleeding (19% vs. 4%, p=0.03). There was no significant difference in major bleeding between the 2 groups. None of the patients in either group developed thrombocytopenia. Conclusion This retrospective small study suggests that the use of GPI in a selected group of elderly patients with acute coronary syndrome may be safe. (J Geriatr Cardiol 2005; 2(4):203-205 )

Meta-analysis of the diagnosis and treatment of traditional medicine for acute coronary syndrome

The morbidity and mortality of acute coronary syndrome disease is extremely high and is the main cause of human death.As an important part of the wisdom of the Chinese nation,TCM plays an important role in treatment.By reviewing recent related research and reports on TCM theories,Chinese herbal formulas,Chinese and Western medicine treatment and other considerations,it aims to provide ideas and references for clinical treatment.

De-escalation of anti-platelet therapy in patients with acute coronary syndromes undergoing percutaneous coronary intervention: a narrative review

Objective:Dual antiplatelet therapy (DAPT) with aspirin and a P2Y12 receptor inhibitor is the cornerstone of treatment in patients with acute coronary syndromes (ACS) and in those undergoing percutaneous coronary intervention (PCI).In current clinical situation, availability of different oral P2Y12 inhibitors (clopidogrel, prasugrel, and ticagrelor) has enabled physicians to switch among therapies owing to specific clinical scenarios.Although optimum time, loading dose and interval of transition between P2Y12 inhibitors is still controversial and needs further evidence, switching between oral inhibitors frequently occurs in clinical practice for several reasons.Data sources:This review was based on data in articles published in PubMed up to June 2018, with the following keywords "antiplatelet therapy" , "ACS" , "PCI" , "ticagrelor" and "clopidogrel" .Study selection:Original articles and critical reviews on de-escalation strategy in ACS patients after PCI were selected.References of the retrieved articles were also screened to search for potentially relevant papers.Results:Safety concerns associated with switching between antiplatelet agents, has prompted the use of clopidogrel for patients with ACS especially after PCI as a de-escalation strategy.Practical considerations for de-escalating therapies in patients with ACS such as reducing dose of P2Y12 inhibitors or shortening duration of DAPT (followed by aspirin or P2Y12 receptor inhibitor monotherapy) as potential options are yet to be standardized and validated.Conclusions:Current review will provide an overview of the pharmacology of common P2Y12 inhibitors, definitions of deescalation and different de-escalating strategies and its outcomes, along with possible direction to be explored in de-escalation.

Situation of antithrombotic therapy in elderly patients with atrial fibrillation and acute coronary syndrome

Background Atrial fibrillation is the most common cardiac arrhythmia in clinical practice. The study examines the situation of antithrombotic therapy in elderly patients （more than 60 years old） with non-valvular atrial fibrillation （NVAF） and acute coronary syndrome （ACS） / percutaneous coronary intervention （PCI）. Methods This study enrolled 381 elderly patients Emean age （69.95 ± 8.41） years; 289 males, 92 femalesl with NVAF and ACS/PCI between January 2006 and September 2013. According to clinical data, these patients were categorized into 4 groups： triple therapy （TT） group, dual antiplatelet therapy （DAT） group, vitamin K antagonist （VKA） plus single antiplatelet therapy （SAT） group and VKA group. According to score of CHA2DS2-VASc and HAS-BLED, all the patients were divided into 4 combinations. Statistical methods were used to analyze the situation of antithrombotic therapy and potential associations between the different combinations. Results 38 patients （9.97%） received TT and 300 patients （78.74%） received DAT. TT was received in 20 patients with CHA2DS2-VASc ≥2 and HAS-BLED ≥3, and 16 patients with CHA2DS2- VASc≥2 and HAS-BLED 〈 3. Conclusions Elderly patients who suffered NVAF and ACS/PCI were with high risk of stroke and low risk of bleeding. Majority of these patients received DAT instead of TT.

A Comparative Study on Post-intervention Use of Tirofiban or Enoxaparin in Patients With Acute Coronary Syndrome Undergoing Percutaneous Coronary Intervention

Objectives To evaluate the efficacy and safety of post procedure use of platelet glycoprotein Ⅱb/Ⅲ a receptor in- hibitor （PGI） or low molecular weight heparin （LMWH） in patients with acute coronary syndrome （ACS） undergoing dual anti-platelet loading therapy and percutaneous coronary intervention （PCI）. Methods This was a prospective randomized grouping controlled study in 174 patients with ACS received aspirin 300 mg plus clopidogrel 600mg loading before PCI. After procedure, patients were randomized to intravenous tirofiban for 12 -24 hours （tirofiban group） or subcutaneous enoxaparin for 5 days （enoxaparin group）. Cardiac ischemic events, major bleeding complications, minor bleeding complications, thrombocytopenia, and vascular access complications in both groups were investigated. Results Cardiac ischemic events, major bleeding complications, minor bleeding complications, thrombocytopenia, and vascular access complications in tirofiban group were 8.0% , 3.4% , 6.8% , 3.4% , and 3.4% , respectively. In enoxaparin group, aforementioned event rates were 7%, 2. 3%, 6. 0%, 2. 3%, and 5.8%, respectively. No statistical significance was found between two groups. Conclusions In the setting of dual anti-platelet medication loading and PCI for the treatment of ACS, it is effective to use tirofiban or enoxaparin for aggressive post procedure antithrombotic therapy. It comes with a very low major bleeding complication rate. Use of GPI for 12 to 24 hours was comparable to use of LMWH for 5 days in efficacy and safety.

What is the Optimal Duration of Dual Antiplatelet Therapy After Stenting?

The optimal duration of dual antiplatelet therapy(DAPT)of aspirin and a P2Y12 receptor blocker after stenting is still being debated.The current recommendations for DAPT duration are signifi cantly focused on reducing stent thrombosis;a less frequent event with later than earlier generation drug eluting stents(DES).A persistent occurrence of late and very late stent thrombosis with first generation DES supported extended use of DAPT beyond one year.However,recent studies have demonstrated that extended duration DAPT is associated with increased bleeding;an independent predictor for poor outcomes,including long-term mortality.Second-generation DES are associated with less late and very late stent thrombosis.Some recent studies have supported a shorter duration of DAPT for second generation DES.However,these studies were inadequately powered to assess signifi cant differences in stent thrombosis.Furthermore,extended duration DAPT has been associated with a reduced risk of thrombotic events in non-culprit vessels in addition to stent thrombosis in patients with acute coronary syndromes(ACS).The higher risk of bleeding associated with extended DAPT therapy provides a strong rationale for personalized DAPT based on patient risk factors(e.g.ACS vs.non-ACS),type of stents,and cost-benefit analyses.

Modern Antiplatelet Therapy:When Is Clopidogrel the Right Choice?

Platelet inhibition with aspirin is the cornerstone of medical therapy for coronary artery disease.In the era of percutaneous coronary intervention with drug-eluting stents,dual anti-platelet therapy with the addition of clopidogrel(Plavix,Bristol-Myers Squibb,New York,NY)became the mainstay of therapy.However,with the advent of newer oral antiplatelet medications,including prasugrel(Effient?,Eli Lilly,Indianapolis,Indiana)and ticagrelor(Brilinta?,Astra-Zeneca,Cambridge,United Kingdom),choosing the appropriate platelet inhibitor has become more nuanced.The optimal regimen differs based on patient characteristics,clinical situation,and the condition being treated,with differing risk and safety profiles for these medications.This review explores the appropriate use of antiplatelet therapy for stable ischemic heart disease,acute coronary syndrome,stroke,and peripheral vascular disease.Furthermore,we evaluate the data behind the use of antiplatelet therapy in patients on oral anticoagulation.By understanding the biochemistry of platelet aggregation,the pharmacology of platelet inhibitors,and the extensive clinical trial data that informs current guideline recommendations we aim to better understand the role of clopidogrel in patients with cardiovascular disease.

基层医院急性冠脉综合征患者药物治疗管理模式的建立

目的:探讨基层医院急性冠脉综合征(ACS)患者药物治疗管理模式的建立及效果评价。方法:结合基层医院现状创建ACS患者药物治疗管理模式。成立医师、药师联合管理团队,制订标准管理流程,对患者进行全程用药管理。比较标准管理模式和传统管理模式下患者关于药物治疗认知、用药依从性、危险因素控制、用药合理性等方面的差异。结果:标准管理模式下的患者药物治疗认知、用药依从性及血压、心率、血脂、血糖等指标达标率均高于传统管理模式患者;除“药物剂量过高”外,其他用药相关问题发生率均低于传统管理模式患者(均P<0.05)。结论:基层医院开展药物治疗管理可提高ACS患者的用药依从性及危险因素达标率,减少不合理用药,建议在基层医院推广。

替格瑞洛递减联合尼可地尔对老年急性冠脉综合征PCI术后干预的有效性和安全性

目的探索老年急性冠脉综合征(ACS)患者经皮冠状动脉介入(PCI)术后替格瑞洛递减治疗与尼可地尔联合干预的有效性和安全性。方法纳入2016年11月-2019年6月于解放军总医院第六、第七医学中心及北京朝阳中西医结合急诊抢救医院诊治的300例老年ACS患者,男153例,女147例,年龄>65岁,所有患者均接受PCI治疗,均为双联抗血小板治疗(DAPT)评分≥2分,新型DAPT评分(PRECISE-DAPT)≥25分的老年患者。所有患者术前采用随机数字表法分为替格瑞洛组(n=146,给予替格瑞洛180 mg负荷剂量后行PCI,术后给予替格瑞洛90 mg bid)与替格瑞洛递减+尼可地尔组(n=154,给予替格瑞洛180 mg负荷剂量后行PCI,术后给予替格瑞洛90 mg bid+尼可地尔5 mg tid,6个月后改为替格瑞洛60 mg bid+尼可地尔5 mg tid)。随访12个月。观察两组患者12个月内出现的心血管死亡、心肌梗死、卒中的复合终点,PLATO研究定义轻微出血、次要出血、其他主要出血和主要致命/危及生命的出血的复合终点,以及心血管死亡、心肌梗死、卒中与出血的复合终点。结果两组患者一般基线资料比较差异均无统计学意义(P>0.05);两组心血管死亡、心肌梗死、卒中的复合终点差异无统计学意义(P>0.05)。而替格瑞洛递减+尼可地尔组出血事件的累积发生率明显低于替格瑞洛组(P<0.05);心血管死亡、心肌梗死、卒中与出血事件的复合终点也明显低于替格瑞洛组(P<0.05)。结论老年ACS患者PCI术后替格瑞洛递减+尼可地尔治疗可不增高心血管死亡、心肌梗死及卒中等缺血性事件的发生率,且可降低出血性事件的发生率。

基于AGREEⅡ的急性冠脉综合征患者抗血小板药物治疗的指南评价

目的:采用临床指南研究与评估系统Ⅱ(AGREEⅡ)工具,对2010—2019年国内外公开发表的急性冠脉综合征(ACS)患者抗血小板药物治疗相关临床实践指南进行方法学评价。方法:选取2010—2019年国内外公开发表的ACS患者抗血小板药物治疗指南及相关文献为研究对象,使用AGREEⅡ对其进行系统评价,并分析各指南推荐内容的差异。结果:共纳入相关文献10篇,其中7篇治疗指南,3篇专家建议与共识。AGREEⅡ各领域的平均得分,范围和目的为(82.5±8.7)%,参与人员为(67.5±15.3)%,制定的严谨性为(68.7±18.2)%,表达的清晰性为(89.3±4.0)%,应用性为(68.1±13.8)%,编辑的独立性为(54.8±12.3)%,总体评价为(65.7±12.3)%。组内相关系数及95%CI为0.89(0.72~0.92),说明研究员评分一致性较高。指南均推荐术后使用阿司匹林+P2Y12受体拮抗剂双联抗血小板治疗。结论:临床实践指南用药推荐术后使用阿司匹林+P2Y12受体拮抗剂双联抗血小板治疗,用药疗程为12个月。ACS患者非必要无需进行基因检测。

延长双联抗血小板治疗时程对急性冠状动脉综合征行经皮冠状动脉介入治疗患者预后的作用

目的探讨延长双联抗血小板治疗(DAPT)时程对急性冠状动脉综合征(ACS)行经皮冠状动脉介入治疗(PCI)患者预后的影响。方法入选2017年6月至2022年8月在廊坊市人民医院住院行PCI的ACS患者1175例,所有患者均接受标准12个月的DAPT治疗且未发生主要不良心脑血管事件(MACCE)和出血事件。根据患者是否继续延长DAPT时程,将患者分为标准治疗组545例和延长双抗组630例。标准治疗组DAPT时程为12个月,延长双抗组延长DAPT时程至术后18~24个月,随访至术后24个月。研究的主要终点为随访期间发生的MACCE,包括心源性死亡、心肌梗死、脑卒中和缺血驱动的再次血运重建的复合终点,次要终点为出血事件,包括大出血和小出血事件。结果和标准治疗组患者相比,延长双抗组患者MACCE发生率降低,差异有统计学意义(χ^(2)=3.892,P<0.05)。在安全性方面,延长双抗组出血事件增加(χ^(2)=7.475,P<0.01),主要归因于小出血事件的增加(χ^(2)=6.061,P<0.05)。Cox回归分析显示,患者的病变血管支数是MACCE发生的影响因素(HR=0.389,P<0.01)。结论对于行PCI治疗的ACS患者,与标准12个月的DAPT时程相比,延长DAPT时程至18~24个月,可降低患者MACCE的发生但增加了患者小出血的风险。