冠心病介入术后行非心脏外科手术的抗栓策略研究

目的 明确药物涂层支架植入患者行非心脏手术围手术期应用Ⅱb/Ⅲa受体拮抗剂替代口服双联抗血小板药物是否发挥预防支架内血栓的作用,同时不增加外科手术的出血.方法 入选入院前1年内曾因冠心病植入药物涂层支架服用双联抗血小板药物(阿司匹林和氯吡格雷)而后无缺血性胸痛症状,心功能纽约分级为2级,年龄60 ～75岁,因外科疾病保守治疗无效需手术治疗的6例患者,手术前5d停用口服双联抗血小板药物,应用Ⅱb/Ⅲa受体拮抗剂替罗非班0.1 μg/( kg· min)持续静脉微量泵泵入,外科手术前2h停用替罗非班,手术结束后在重症监护室中应用替罗非班0.1 μg(kg· min)持续静脉微量泵泵入,术后根据外科情况允许,停用替罗非班,尽早恢复口服双联抗血小板药物使用.分析围手术期新发心血管事件,特别是支架内血栓事件,以及严重出血事件,替罗非班的药物不良反应事件.结果6例患者围手术期均未发生缺血性室性恶性心律失常、心绞痛、心肌梗死、心源性猝死,未发生大量出血而导致输血或需二次手术止血等出血事件,并且未发生替罗非班的药物不良反应.结论药物涂层支架植入术后患者行非心脏手术Ⅱb/Ⅲa受体拮抗剂替代口服双联抗血小板药物预防围手术期支架内血栓的治疗措施可能是可行的和安全的,但需要大样本随机对照试验以进一步证实.

Antithrombotic strategy for non-cardiac surgery after percutaneous coronary intervention

Objective To elucidate whether taking Ⅱ b/Ⅲ a receptor antagonist instead of oral antiplatelet drugs during perioperative in patients with drug-eluting stent implantation undergoing non-cardiac surgery would play a preventive role of stent thrombosis,without increasing surgical bleeding.Methods Six patients aged 60 -75 years old with drug-eluting stent implantation within 1 year taking dual antiplatelet drugs without any chest pain,and whose heart function classification for two (NYHA) were enrolled.They underwent surgical treatment due to ineffective conservative treatment of surgical disease,5 days before surgery intravenous infusion tirofiban 0.1 μg/( kg · min) micro pumps continuously instead of oral dual antiplatelet drugs,2 hours before surgery stop tirofiban and re-application of tirofiban 0.1 μg/( kg · rain) after surgery in the intensive care unit,and replacing tirofiban with oral dual antiplatelet as soon as possible according to the situation.Analyze cardiovascular events,especially stent thrombosis events and seriously bleeding,tirofiban adverse drug events during perioperative.Results Six patients have no perioperative malignant ischemic ventricular arrhythmia,angina,myocardial infarction,sudden cardiac death,no massive bleeding and adverse drug reactions.Conclusion Substitution of oral dual antiplatelet drugs for Ⅱ b/Ⅲ a receptor antagonists to prevent stent thrombosis treatment during perioperative in patients with drug-eluting stent implantation undergoing non=cardiac surgery may be feasible and safe,but needs to be further confirmed through large sample of randomly controlled trials.