血栓弹力图评价急性冠状动脉综合征患者介入术后血小板高反应性对不良预后影响分析

目的:探讨由血栓弹力图(TEG)测定二磷酸腺苷激活血小板形成最大血凝块强度(MAADP),评价急性冠状动脉综合征(ACS)经皮冠状动脉介入治疗术(PCI)后,与氯吡格雷治疗相关的血小板高反应性(HTPR)对预后的影响。方法:入选2011年1月至2012年9月,行PCI术的ACS患者360例。使用TEG检测其血小板的反应性,记录患者基线资料,并进行12个月随访,记录心脏不良事件的发生情况(全因性死亡、非致死性心肌梗死、再次血运重建及反复心绞痛导致再住院等)。结果:采用受试者工作特征(ROC)曲线分析TEG检测ACS患者HTPR的MA-ADP最佳界值47mm,并依此分组,HTPR组71例,NTPR组289例。与NTPR组相比,HTPR组女性(39.4%vs.23.9%,P0.05),非ST段抬高性心肌梗死(14.1%vs.5.5%,P0.05),糖尿病(45.1%vs.31.5%,P0.05),高敏C反应蛋白(3.2vs.1.4,P0.05),纤维蛋白原[(3.2±0.7)vs.(2.9±0.7),P0.05]较高。Logistic回归显示女性、纤维蛋白原升高是TEG测定的HTPR的独立危险因素(OR=2.011,95%CI:1.144~3.533;OR=1.624,95%CI:1.122~2.350,P0.05);COX回归分析MAADP47mm是缺血事件的危险因素(HR=4.863,95%CI:2.505~9.439,P0.05)。结论:TEG测定的MAADP评价HTPR可预测ACS患者PCI术后再发缺血事件。     

血栓弹力图在冠心病抗血小板治疗中的临床应用体会

目的研究血栓弹力图在冠心病抗血小板治疗中的临床应用效果。方法本次纳入2018年5月至2019年4月期间在本院进行抗血小板治疗的110例冠心病患者展开研究,根据疾病分型划分为急性心肌梗死组40例、不稳定型心绞痛组40例、稳定型心绞痛组30例。采用血栓弹力图检测三组抗血小板治疗的相关参数、凝血功能指标,统计心脏不良事件发生情况。结果三组的R、K、LY30、APTT呈上升趋势,CI、Angle、MA、FIB、D-D呈下降趋势,抗血小板治疗药物反应正常者的心脏不良事件发生率低于反应低下者,差异具有统计学意义(P<0.05)。结论血栓弹力图可为冠心病抗血小板治疗中的临床用药提供指导,有助于防范心脏不良事件的发生。     

血栓弹力图仪血小板检测对比研究

目的探讨裕泽毅公司血栓弹力图仪(YZ)与美国血技公司血栓弹力图仪(TEG)检测血小板功能的相关性以及抗血小板药物抑制率检测效果。方法抽取20例患者的静脉血,分别留取枸橼酸和肝素抗凝血样各2管,分别用YZ和乐普公司血小板检测仪及试剂与TEG血小板检测试剂进行血小板功能平行测定,观察其相关性。结果两种方法检测同一血样测得的凝血因子激活时间(R)分别为:YZ法(8.22±2.74)min,TEG法(8.05±2.97)min,P0.05;最大血块强度(MA)分别为:YZ法(66.00±7.66)mm;TEG法(65.68±7.62)mm,P0.05。通过秩和检验分析,两种方法检测AA抑制率:YZ法(72.97±24.78)%;TEG法(72.55±27.16)%,P0.05;ADP抑制率:YZ法(58.85±28.99)%;TEG法(58.43±29.37)%,P0.05。两种方法检测AA抑制率50%的患者比例均为80%,ADP抑制率50%的患者比例均为65%,通过秩和检验分析P0.05。结论使用裕泽毅血栓弹力图仪与TEG血栓弹力图仪及试剂检测血小板功能及抗血小板药物抑制率效果良好,结果具有相关性,能为临床医生提供可靠、准确、有价值的诊断指导依据。     

真实世界里根据血栓弹力图指导冠脉介入患者抗栓治疗的实际意义

【摘要】：目的 探讨真实世界里根据血栓弹力图（Thrombelastogram, TEG）指导个体化抗血小板治疗对冠状动脉粥样硬化性心脏病(冠心病)支架植入术后的患者长期预后的影响。方法 搜集2015年3月至2018年9月于首都医科大学宣武医院心脏科因冠心病行支架植入术且氯吡格雷低反应（Clopidogrel low-responsiveness, CLR）的患者360例,根据患者实际口服抗血小板聚集药物分为氯吡格雷组（n=240）和替格瑞洛组（n=120）。随访24月,观察两组患者全因死亡、主要不良心脑血管缺血事件（Major adverse cardiac cerebrovascular events, MACCEs）及出血并发症的发生率。结果 在24个月的临床随访中,两组共有18名患者死亡、115名患者发生了MACCEs事件。与替格瑞洛组患者相比,氯吡格雷组患者全因死亡发生率（5.8% VS 4.6% P=0.608）无显著差异,而MACCEs事件发生率（23.3% VS 36.3% P＜0.05）明显升高,并且MACCEs事件中支架内血栓形成（5.0% VS 11.7% P=0.041）及再次血运重建（5.8% VS 12.9% P=0.039）的发生率两组间存在显著差异。而两组患者出血发生率无显著差异（P＞0.05）。而对于是否更换抗血小板药物是冠心病PCI术后的氯吡格雷低反应性患者发生MACCEs事件独立的危险因素。结论 在TEG指导下,调整替格瑞洛联合阿司匹林抗血小板治疗将有助于降低氯吡格雷低反应性的冠心病PCI术后患者心脑血管事件的发生率,且出血事件发生率相似,改善长期预后。     

血栓弹力图指导个体化抗血小板治疗对PCI术后患者临床预后的影响

目的 研究血栓弹力图指导下的个体化抗血小板治疗对临床预后的影响.方法 选取第二炮兵总医院2012年1月至2014年4月在心内科住院的冠状动脉支架植入患者680例,在PCI术后72 h后行血栓弹力图检测,根据检测结果对氯吡格雷抑制率＞20％者行常规治疗;将氯吡格雷抑制率＜20％者分为2组：西洛他唑组在常规治疗基础上增加西洛他唑治疗,替格瑞洛组将氯吡格雷更换为替格瑞洛治疗.三组均随访3个月,统计心脏不良事件（心血管死亡、非致死性心肌梗死、卒中或靶血管血运重建）发生率.结果 常规组MACE事件发生率为8.9％,西洛他唑组MACE事件发生率为8.3％,两组比较差异无统计学意义（P＞0.05）;替格瑞洛组MACE事件发生率为3.6％,显著低于常规组及西洛他唑组（P＜0.05）.结论 血栓弹力图指导的抗血小板治疗对选择药物治疗方案有一定指导意义。     

急性冠状动脉综合征患者血栓弹力图特征及临床意义研究

目的:探讨急性冠状动脉综合征(ACS)患者血栓弹力图(TEG)的特征及临床意义。方法:选择90例ACS患者为研究组,其中包括不稳定性心绞痛31例(UA组),急性ST段抬高型心肌梗死31例(STEMI组),急性非ST段抬高型心肌梗死28例(NSTEMI组);同时选择100例门诊体检健康者为对照组,所有受试者均接受TEG检测。ACS患者接受急诊经皮冠脉介入术(PCI)和抗血小板治疗,PCI术后次日、抗血小板治疗后1个月进行TEG检测。比较各组TEG指标[凝血反应时间(R),血凝块成形时间(K)、最大振幅(MA)、MA后30 min振幅减少百分率(LY30)、血凝块形成速率(Angle)、凝血指数(CI)],以MA、花生四烯酸诱导的血小板抑制率(AA)评价抗血小板治疗效果。结果:ACS患者R[(4.65±1.05) min对(5.62±1.13) min]、K[(1.68±0.61) min对(2.46±0.93) min]、LY30(1.02±0.23对1.62±0.31)低于对照组;Angle(66.41°±12.35°对54.69°±8.85°)、MA[(62.65±10.17) mm对(55.38±9.27) mm]、CI(1.48±0.59对-0.85±0.32)高于对照组,差异均有统计学意义(P均0.05)。STEMI组MA[(66.38±10.27) mm]高于NSTEMI组[(62.27±9.38) mm]和UA组[(59.25±12.05) mm],差异均有统计学意义(P均0.05)。研究组治疗后MA从(62.51±10.62) mm下降至(51.52±8.73) mm,AA从(43.62±12.51)%升高至(77.85±16.95)%,差异有统计学意义(P0.05)。结论:TEG指标能有效反映ACS患者病情,评价临床抗凝治疗效果,可用于临床监测,指导治疗。     

冠状动脉搭桥术后患者对抗血小板药物低反应性的危险因素分析

目的探究行冠状动脉搭桥手术后发生高血小板反应性的影响因素。方法选择2015年5月至2016年5月行冠状动脉搭桥术并符合纳入标准的患者90例,术后服用阿司匹林肠溶片和氯吡格雷片双联抗血小板治疗且行血栓弹力图检测,查阅病案系统建档并电话随访1年,记录患者随访期间发生的缺血事件和出血事件,分为高血小板反应性组和正常血小板反应性组,评估血栓弹力图检测的高血小板反应性与冠状动脉搭桥患者对应因素的相关性。结果年龄、尿酸、谷丙转氨酶、谷草转氨酶、术中输血量、24 h引流量、手术时长、术后血栓弹力图指标(血块动力K、血块强度MA_(thrombin)、凝血综合指数CI、血块强度MA_(ADP))有统计学差异(P0.05)。多因素二元Logistic回归分析显示尿酸升高与发生高血小板反应性呈正相关(OR=1.011,95%CI为1.003~1.019,P0.05)。结论尿酸升高可能是导致冠状动脉搭桥患者对抗血小板药物反应低下的危险因素。     

血栓弹力图指导的抗血小板治疗对支架内再狭窄患者预后的影响

目的 探讨血栓弹力图检查指导下的双联抗血小板治疗对经皮冠状动脉介入治疗(PCI)术后支架内再狭窄(ISR)患者临床预后的影响。方法 选取2017年1月至2020年1月中国人民解放军总医院第一医学中心心血管内科收治的经冠状动脉造影确诊为PCI术后ISR的患者275例。完善血栓弹力图(TEG)检查,根据二磷酸腺苷(ADP)途径诱导的血小板抑制率(ADP抑制率)和ADP途径曲线最大振幅(MA)是否达标,将患者分为对照组(n=184)、氯吡格雷组(n=57)和替格瑞洛组(n=34),给予阿司匹林联合氯吡格雷或替格瑞洛治疗。出院后每6个月随访一次,分析3组患者长期预后的差异。采用SPSS 25.0软件进行统计分析。采用logistic回归法分析影响ISR患者预后的危险因素。结果 随访时间15～52[26(18,34)]个月。对照组患者ADP抑制率显著高于氯吡格雷组和替格瑞洛组[(85.63±13.57)%和(37.60±8.19)%,(22.74±9.76)%;P＜0.05];替格瑞洛组MA-ADP显著高于对照组及氯吡格雷组[(52.16±4.82)和(17.01±9.08),(38.69±4.68)mm;P＜0.05]。替格瑞洛组换药后ADP抑制率显著升高[(22.74±9.76)%和(81.04±15.01)%],MA-ADP显著降低[(52.16±4.82)和(17.06±9.26)mm],差异均有统计学意义(均P＜0.05)。氯吡格雷组的主要不良心血管事件(MACE)发生率和全因死亡率显著高于对照组和替格瑞洛组(均P＜0.05)。ADP抑制率是ISR患者治疗术后再次入院、行冠状动脉造影检查、再次PCI、心源性死亡及MACE的保护性因素。随着ADP抑制率的升高,MACE发生率显著降低(OR=0.56,95%CI 0.42～0.76;P＜0.001)。结论 ADP抑制率是ISR患者治疗术后MACE事件发生的保护因素,在TEG指导下采用有效的DAPT方案可以显著降低ISR患者MACE发生率,改善患者预后。     

血栓弹力图监测抗血小板药物抑制率在老年急性冠脉综合征患者临床治疗中的价值

目的:应用血栓弹力图(TEG)监测老年急性冠脉综合征(ACS)患者不同抗血小板药物的血小板抑制率,评估药物疗效。方法:选取2018-01—2019-06住院的老年ACS患者(年龄≥60岁)234例,应用TEG监测并比较在不同诱导途径下抗血小板药物的抑制率,随访出院后6个月内患者出血及不良心血管事件(MACE)等发生情况。结果:2组发生四烯酸(AA)途径血小板抑制率比较,差异无统计学意义(t=1.274,P=0.078);A组较B组二磷酸腺苷(ADP)途径血小板抑制率高,药物抵抗的发生率低,差异有统计学意义(t=2.421,P=0.035)。2组抗血小板药物AA途径低反应性比较,差异无统计学意义(χ²=0.17,P=0.623);A组ADP途径低反应性明显低于B组,差异有统计学意义(χ²=9.15,P=0.004)。A组MACE发生率低于B组,差异有统计学意义(χ²=4.60,P=0.043);A组呼吸困难发生率高于B组,差异有统计学意义(χ²=8.98,P=0.005);2组出血事件发生率比较,差异...     

Oral antiplatelet therapy for percutaneous coronary revascularization.

Great strides in interventional pharmacotherapy have been made over the past few decades, virtually all focused on optimizing peri-PCI antithrombotic therapy in order to reduce thrombotic complications. Our understanding of the role of platelets and of antiplatelet therapies in this process continues to evolve. Today, dual or even triple antiplatelet therapy has become standard of care at the time of PCI followed by dual therapy long-term in the majority of patients. However, currently available oral regimens are hampered by limitations including the need to initiate treatment at least a few hours before the procedure to achieve maximum benefit and the safety issues surrounding irreversible platelet inhibition in the uncommon, but not rare situations when a patient requires surgical revascularization. These limitations have led to the suboptimal "real-world" utilization of these proven agents and have fostered the development of a wide variety of alternative platelet inhibitors with theoretical, but still unproven clinical benefits. There are ample clinical data that strongly support the use of aspirin and clopidogrel in virtually all patients undergoing a PCI today. This review will highlight these data as well as emphasize the gaps in our understanding. (c) 2007 Wiley-Liss, Inc.     

Analysis of individualized antiplatelet therapy for patients of acute coronary syndrome after percutaneous coronary intervention under the guidance of platelet function: A one-center retrospective cohort study

There is controversy in clinical application of antiplatelet drugs by monitoring platelet function. Therefore, we explored whether early and dynamic medication could bring better clinical outcomes for patients under the guidance of platelet function tests (PFT).In this retrospective cohort study, we analyzed the prognostic events of 1550 patients with acute coronary syndrome (ACS) at Tianjin People''s Hospital in China. They received dual antiplatelet therapy (DAPT) after percutaneous coronary intervention (PCI) from January 2017 to December 2018. The primary endpoint was based on the Bleeding Academic Research Consortium (BARC) 3 or 5 major bleeding. Secondary endpoints included MACCE (all-cause death, nonfatal myocardial infarction, stroke, stent thrombosis, and unplanned target vessel reconstruction) and BARC 1 to 2 minor bleeding. The endpoint events within 1 year after PCI were recorded. Patients were divided into a guided group and a control group according to the drug adjustment by PFT results. After the propensity scores matched, the end points of 2 groups were compared, and subgroup analysis was performed on major bleeding events.After propensity score matching, there were 511 cases in the guided group and the control group, respectively. The primary endpoint events occurred in 10 patients (1.96%) in the guided group and 23 patients (4.5%) in the control group (HR: 0.45; 95% CI, 0.21–0.95; P = .037). After the guided group adjusted drug doses, the risk of major bleeding was lower than standard DAPT of the control group. Although some patients in the guided group reduced doses earlier, the incidence of MACCE events did not increase in the guided group compared with the control group (4.89% vs 6.07%; P = .41). There was no statistical difference in BARC 1 to 2 minor bleeding (P = .22). Subgroup analysis showed that PFT was more effective in patients with diabetes and multivessel disease.Early observation of dynamic PFT in ACS patients after PCI can guide individualized antiplatelet therapy to reduce the risk of major bleeding without increasing the risk of ischemia.     

Urgent or emergent coronary revascularization using bilateral internal thoracic artery after previous clopidogrel antiplatelet therapy

BACKGROUND: Application of clopidogrel before diagnostic or therapeutical percutaneous coronary interventions has become standard for stent-thrombosis prevention. The irreversible platelet inhibition causes increasing bleeding complications if urgent coronary artery bypass grafting becomes necessary. This study evaluates the effect on bleeding complications of clopidogrel in urgent CABG using bilateral internal thoracic artery (ITA) and saphenous veins in all patients. METHODS: We retrospectively analyzed 166 patients (operated between 1/00-12/02) with urgent or emergency CABG, using both ITAs and compared 83 patients with previous (within 5 days) clopidogrel and aspirin application to 83 patients without clopidogrel. We evaluated chest tube output, reexploration rate and necessity of blood products, ventilation time and ICU stay. RESULTS: Both groups were comparable with age, gender, number of performed anastomoses (mean 4/ patient). Chest tube output (24 h) was higher in the clopidogrel group (935 +/- 599 ml vs 754 +/- 335 ml (p = 0.018)), as well as reexploration rate with 7.2% (6 of 83) vs 0% (0 of 83) (p < 0.001). Number of blood products in the clopidogrel group for red cells was 2.41 +/- 1.88 U vs 1.84 +/- 1.47 U p = 0.03, for plateletes 0.43 +/- 0.88 U vs 0.024 +/- 0.22 p = 0.0001, for fresh frozen plasma 0.41 +/- 1.14 U vs 0.096 +/- 0.59 U p = 0.029. Mechanical ventilation time was 11.35 +/- 8.77 h vs 10.57 +/- 9.12 h p = 0.51, ICU stay 32.1 +/- 21.8 h vs. 29.8 +/- 21.1 h (p = 0.48). CONCLUSIONS: Previous application of clopidogrel in combination with aspirin before urgent CABG induces increased chest tube output, reexploration rate and necessity of blood products, especially of plateletes. Nevertheless, routine use of both ITAs in patients after clopidogrel exposure can be performed with acceptable bleeding complications.     

Urgent or emergent coronary revascularization using bilateral internal thoracic artery after previous clopidogrel antiplatelet therapy

BACKGROUND: Clopidogrel application before diagnostic or therapeutical percutaneous coronary intervention has become the standard for stent thrombosis prevention. Irreversible platelet inhibition causes increasing bleeding complications if urgent coronary artery bypass grafting is necessary. This study evaluates the effect on bleeding complications of clopidogrel in urgent CABG using bilateral internal thoracic artery (ITA) and saphenous veins in all patients. METHODS: We retrospectively analyzed 128 patients (operated between January 2000 and September 2002) undergoing urgent or emergent CABG using both ITAs, and compared 64 patients with previous clopidogrel and aspirin application (within 5 days) to 64 patients without clopidogrel. We evaluated chest tube output, re-exploration rate and necessity of blood products, ventilation time and ICU stay. RESULTS: Both groups were comparable in age, gender, number of performed anastomoses (mean 4/patient). Chest tube output (24 h) was higher in the clopidogrel group at 977+/-628 ml vs. 788+/-389 ml (p=0.046), as was re-exploration rate with 7.81% (5 of 64) vs. 0% (0 of 64) (p<0.005). The number of blood products amounted to 2.7+/-1.9 U in the clopidogrel group vs. 1.9+/-1.6 U (p=0.013) for red cells, 0.05+/-0.9 U vs. 0.03+/-0.25 (p=0.0003) for platelets, and 0.5+/-1.3 U vs. 0.2+/-1.0 U (p=0.14) for fresh frozen plasma. Mechanical ventilation time was 11.9+/-9.7 h vs. 9.6+/-5.9 h (p=0.10), ICU stay 32.6+/-22.1 h vs. 27.8+/-18.2 h (p=0.19). CONCLUSIONS: Previous application of clopidogrel in combination with aspirin before urgent CABG induces increased chest tube output, re-exploration rate and necessity of blood products, especially platelets. Nevertheless, routine use of both ITAs in patients after clopidogrel exposure can be performed with acceptable bleeding complications.     

Medical therapy after successful percutaneous coronary revascularization

BACKGROUND: Percutaneous coronary revascularization frequently relieves angina in patients with ischemic heart disease and may obviate the need for antianginal medications. OBJECTIVE: To examine the use of antianginal medications after successful percutaneous coronary revascularization. DESIGN: Retrospective cohort study of the Mayo Clinic PTCA [percutaneous transluminal coronary angioplasty] Registry. SETTING: Tertiary care center. PATIENTS: 3831 patients who underwent successful percutaneous coronary revascularization from September 1979 through August 1997 and had not had myocardial infarction within the year before the intervention. MEASUREMENTS: Use of antianginal medications (beta-adrenergic blockers, nitrates, and calcium-channel blockers) before the intervention, at hospital discharge, and 6 months after the intervention. RESULTS: 99% of patients reported improvement in their symptoms at hospital discharge. At 6 months, 87% of patients were free of myocardial infarction, coronary bypass surgery, or additional percutaneous intervention. Compared with 66% of patients before the index intervention, only 12% of patients had severe angina at 6 months and 69% were completely free of angina. Nonetheless, at 6 months, 39% of patients were receiving beta-adrenergic blockers (preprocedure proportion, 43%; P < 0.001), 36% were receiving nitrates (preprocedure proportion, 41%; P < 0.001), and 57% were receiving calcium-channel blockers (preprocedure proportion, 50%; P < 0.001). These trends persisted for patients without hypertension and those who had complete revascularization. CONCLUSIONS: Successful percutaneous coronary revascularization did not substantially supplant the use of antianginal medications, which were commonly used despite the marked improvement in anginal status. This may reflect reluctance to alter therapy once symptoms of angina subside. Guidelines on continued medical therapy after percutaneous coronary revascularization are needed.     

冠状动脉介入治疗术后抗血小板药物治疗的现况分析

目的了解经皮冠状动脉介入治疗(PCI)术后抗血小板药物的应用是否规范,并对其可能的原因进行分析。方法对2001-07-01—2002-06-30与2003-07-01—2004-06-30两个时间段内,于首都医科大学附属北京安贞医院心内科行PCI治疗的注册研究患者进行回顾分析,研究其术后抗血小板治疗药物的种类、联合用药、药物剂量及服用时间。结果1728例患者接受了PCI治疗,其中1006例患者置入药物洗脱支架(DES组),518例置入普通金属支架(BMS组),192例患者同时置入了DES与BMS,12例患者单纯球囊扩张。术后有70例患者未继续使用任何抗血小板治疗药物。其余1658例患者使用1种或1种以上抗血小板治疗药物。进一步分析BMS组与DES组术后抗血小板药物的使用情况,术后未使用任何抗血小板药物(BMS组52例,DES组18例,P<0.001),只使用阿司匹林一种抗血小板药物(BMS组236例,DES组180例,P<0.001),只使用噻吩并吡啶类药物(BMS组45例,DSE组39例,P>0.05),使用阿司匹林加噻吩并吡啶类药物双重抗血小板治疗(BMS组350例,DES组808例,P<0.001)。结论冠状动脉介入治疗术后的抗血小板治疗有待进一步加强,提高抗血小板药物的依从性,降低PCI术后并发症的发生。     

长期口服华法林钠患者冠状动脉支架术后抗栓治疗方案的分析

目的:讨论长期口服抗凝剂患者冠状动脉支架术后的抗栓治疗方案。方法:选择长期口服华法林钠,并在北京安贞医院接受冠状动脉造影(CA)和支架术(PCI)的患者,对临床资料进行回顾性分析,根据患者出院用药方案进行分组,比较组间基线特征,以及支架术后再梗死、死亡、脑梗死及出血等事件之间的差别。结果:符合要求的90例患者分为华法林钠+氯吡格雷+阿司匹林三联治疗组(A组)、华法林钠+氯吡格雷二联治疗组(B组)、阿司匹林+氯吡格雷二联治疗组(C组)。最常用治疗方案是停用华法林钠,联用阿司匹林和氯吡格雷。3个治疗组患者的再梗死、死亡、脑血管意外、严重出血及输血治疗等差异无统计学意义。结论:高危血栓栓塞风险患者冠状动脉支架术后应予三联治疗,密切监测凝血酶原时间(PT)和国际标准化比值(INR);而对于低危血栓栓塞风险的患者停用华法林钠,联用阿司匹林和氯吡格雷的治疗方案是可行的。本项调查观察样本量小,证据不够充分。针对不同患者制定相应的抗栓治疗方案,才能在获得良好抗栓疗效的同时减少出血事件。