泮托拉唑对氯吡格雷抗血小板功能的影响研究

目的观察泮托拉唑对氯吡格雷抗血小板功能的影响。方法选取240例急性冠状动脉综合征患者,随机分为两组,对照组（120例）给予氯匹格雷和阿司匹林治疗,泮托拉唑组（120例）在对照组治疗基础上给予泮托拉唑治疗。用药前及用药7d后检测ADP诱导的血小板聚集率。比较前后的血小板聚集率、住院期间及1个月内的主要心血管事件。结果泮托拉唑组和对照组用药前后血小板聚集率及1个月内的主要心血管事件差异无统计学意义（P〉0.05）。结论 泮托拉唑不影响氯吡格雷的抗血小板聚集作用。     

不同质子泵抑制剂对氯吡格雷抗血小板效应影响研究的进展

质子泵抑制剂（PPIs）常被用来预防氯吡格雷与阿司匹林的双联抗血小板治疗引起的消化道出血不良反应,但近年来陆续有研究表明,PPIs可能会拮抗氯吡格雷的抗血小板作用,同时增加主要不良心血管事件（MACE）的发生率;可是也有相反报道,认为它不会增加MACE及死亡率。本文就此争议做一综述。     

不同种类质子泵抑制剂对氯吡格雷抗血小板疗效的影响

氯吡格雷作为一种新型的抗血小板药,已与阿司匹林联合广泛应用于临床,成为冠心病抗血小板药物治疗的基石。双联抗血小板治疗使胃肠道并发症的出现增多,故临床上常规加用质子泵抑制剂,以预防双联抗血小板治疗引发的胃肠道并发症。但国外最新研究发现质子泵抑制剂会影响氯吡格雷的疗效,降低其抗血小板的活性,使临床心血管不良事件发生率增加。     

质子泵抑制剂对氯吡格雷抗血小板效应的影响

急性冠状动脉综合征(ACS)是一组由于冠状动脉粥样硬化斑块破裂、表面破损或出现裂纹引发血小板激活,进而引起冠状动脉内不同程度血栓形成和远端血管闭塞的一组心血管急症,是目前引起死亡的主要原因之一.近年来逐渐认识到其主要病理基础为不稳定斑块引起的血小板继发性激活从而引起冠状动脉局部血栓形成,因此抗血小板治疗是目前治疗急性冠状动脉综合征的基础.因此,美国心脏病学会(ACC)及美国心脏学会(AHA)推荐氯吡格雷联合阿司匹林的双联抗血小板治疗用于不稳定性心绞痛、非ST段抬高型心肌梗塞及行药物溶栓或经皮冠状动脉介入治疗(PCI)治疗的心肌梗塞患者[1].     

雷贝拉唑对氯吡格雷抗血小板聚集作用的影响

目的探讨择期经皮冠状动脉介入治疗(PCI)术的患者中,质子泵抑制剂雷贝拉唑对氯吡格雷的血小板聚集率的影响。方法入组120例行择期PCI的冠心病患者,按照病案号的单双号随机分为雷贝拉唑组和对照组。对照组按常规服用阿司匹林、氯吡格雷口服和其他PCI术前准备,雷贝拉唑组在PCI术后加用雷贝拉唑(20mg/d)共7d。比较两组住院期间7d后血小板聚集率以及PCI术后1个月内临床事件的发生率、便潜血的阳性率。结果雷贝拉唑组和对照组二磷酸腺苷(adenosine diphosphate,ADP)诱导的血小板聚集率分别为32.4%和37.1%(P=0.1971),心肌缺血的发生率分别为3.3%和5.0%(P=0.6478),均未发生严重不良临床事件。雷贝拉唑组和对照组便潜血阳性率分别为0%和6.7%(P=0.0419),PCI术后1月随访时便潜血阳性率分别为0%和8.3%(P=0.0224)。结论合用雷贝拉唑对氯吡格雷的抗血小板聚集作用没有明显影响,同时具有保护消化道、减少消化道出血的机会。     

泮托拉唑对氯吡格雷抑制血小板作用的影响

目的观察泮托拉唑对氯吡格雷血小板抑制作用的影响。方法对我科于2008年1月至2009年12月住院和门诊确诊为冠状动脉疾病并经皮冠状动脉介入治疗(PCI)的患者226例病例进行回顾总结。结果血小板反应指数在治疗组(n=151,总体均数51%,范围48%～54%)和对照组(n=75,总体均数49%,范围43%～55%;P=0.697)的患者中没有明显差异。治疗组(聚集度=47U)和对照组(聚集度=41U;P=0.582)的患者之间,二磷酸腺苷诱导的血小板聚集度没有明显差异。结论对于接受氯吡格雷治疗且同时需要抑酸干预的患者,需要PPI治疗时,应尽可能的选择相互作用影响小的泮托拉唑。     

质子泵抑制剂对氯吡格雷抗血小板疗效的影响

2008年美国心脏病学会基金会、美国胃肠病学会和美国心脏协会专家共识文件指出,对于采用阿司匹林和氯吡格雷双重抗血小板的冠心病患者服用质子泵抑制剂(PPI)可预防和治疗药物相关性胃和十二指肠损伤.然而,PPI通过肝细胞色素P450途径竞争性抑制氯吡格雷的抗血小板聚集作用,从而可能增加心血管事件发生率.该文综述近年来PPI...     

质子泵抑制剂对PCI术后氯吡格雷抗血小板作用的影响

目的 探讨经皮冠状动脉介入术(PCI)后抗血小板治疗中应用质子泵抑制剂(PPI)对氯吡格雷抗血小板作用的影响.方法 选择PCI术后患者336例,术后立即服用氯吡格雷600 mg及阿司匹林500 mg,随后应用氯吡格雷75 mg/d、阿司匹林100 mg/d.术后同时服用PPI类药物以预防消化道出血的患者148例(观察组),其中122例给予口服泮托拉唑,14例给予口服奥美拉唑,12例给予口服埃索美拉唑.没有服用PPI类药物的188例患者作为对照组.在服用氯吡格雷48 h后检测两组血小板聚集率,以氯吡格雷抵抗(CLR)评价抗血小板聚集效果.比较不同PPI药物与CLR的相关性.结果 两组血小板阻抗变化差异无统计学意义(P均＞0.05).两组CLR发生率差异无统计学意义(P＞0.05).奥美拉唑、埃索美拉唑对CLR影响较大.结论 接受氯吡格雷+阿斯匹林双重抗血小板治疗的患者服用PPI标准剂量时,短期内不影响氯吡格雷的抗血小板作用.     

氯吡格雷和质子泵抑制剂相互作用争议,尘埃落定?

双联抗血小板治疗可显著降低急性冠状动脉综合征,尤其是经皮冠状动脉介入治疗术后患者的再发缺血事件和死亡风险.但治疗后常导致患者消化道出血风险增加,加用质子泵抑制剂(PPI)可降低该风险,已成为临床常规治疗.但近年来,氯吡格雷与PPI间的相互作用是否导致心血管事件的增加,倍受临床医生关注,引发了激烈的讨论.     

奥美拉唑不同服药时间对氯吡格雷抗血小板效应的影响

目的:探讨分开氯吡格雷和奥美拉唑的服药时间对氯吡格雷抗血小板效应的影响。方法:入选急性冠状动脉综合征(ACS)患者56例,将其随机分为A组:单用氯吡格雷(21例);B组:氯吡格雷+奥美拉唑(20例);C组:氯吡格雷+奥美拉唑,间隔10～12h(15例)。采用PCR-RFLP检测患者的细胞色素P450(cytochromeP450,CYP)2C19*2和*3基因型,比浊法检测服药前及服药1d、5d的最大血小板聚集率(MPAR)。结果:3组CYP2C19*2和*3基因型的分布差异无统计学意义。服药1d和5d总的氯吡格雷抵抗发生率分别为42.86%和46.43%。服药1d后,A组MPAR与B、C组比较均差异有统计学意义(均P<0.05),而B组和C组差异无统计学意义。结论:联用奥美拉唑降低了氯吡格雷抗血小板效应,分开氯吡格雷和奥美拉唑服药时间不能减轻奥美拉唑对氯吡格雷的影响。     

Dual Antiplatelet Therapy with Prasugrel or Ticagrelor Versus Clopidogrel in Interventional Cardiology

For several years, clopidogrel plus aspirin has been the dual antiplatelet therapy (DAPT) of choice for patients with acute coronary syndrome (ACS) undergoing percutaneous coronary intervention (PCI) with stent implantation. More recently, prasugrel and ticagrelor have demonstrated greater efficacy than clopidogrel. In TRITON-TIMI 38, the risk of TIMI major bleeding unrelated to coronary artery bypass graft (CABG) surgery was similar for prasugrel and clopidogrel after excluding subgroups with increased bleeding risk (previous stroke or transient ischemic event; age ≥75 years; weight <60 kg). In the PLATO trial, rates of TIMI major bleeding were similar for ticagrelor and clopidogrel, but ticagrelor was associated with a significantly higher rate of non-CABG-related TIMI major bleeding. Current evidence suggests that prasugrel or ticagrelor plus aspirin should be the DAPT of choice in patients with ACS undergoing PCI unless they are at particularly high risk of bleeding. No studies have yet compared prasugrel and ticagrelor in ACS patients, however prasugrel and ticagrelor have different side effect profiles, and the choice of agent should be made either as a default choice and/or on an individual patient basis. Ongoing trials in ACS patients will increase the evidence base for new P2Y₁₂ receptor inhibitors and help to establish the most effective DAPT regimens.     

氯吡格雷对冠心病合并慢性肾病患者抑制血小板聚集作用的影响

目的:探讨冠心病患者使用氯吡格雷的效果与患者自身肾功能的关系,为冠心病合并慢性肾病患者用药提供参考。方法:采用回顾性调查的方式选取2014-01至2014-09在我院经冠状动脉造影确认的冠心病患者423例,按照肾小球滤过率(eG FR)分为两组。eG FR≥90 ml/(min·1.73 m2)为冠心病无慢性肾病组共257例,男182例,女75例,平均年龄(60.39±11.09)岁;eG FR90 ml/(min·1.73 m2)为冠心病慢性肾病组166例,男107例,女59例,平均年龄(65.80±10.84)岁。两组患者在服用阿司匹林0.1 g/d和氯吡格雷75 mg/d7 d,或者是因经皮冠状动脉介入治疗手术服用阿司匹林0.3 g和氯吡格雷300 mg的负荷量后,采用血栓弹力图检测二磷酸腺苷(ADP)受体抑制率和花生四烯酸途径抑制率。结果:平均ADP受体抑制率冠心病无慢性肾病组[(64.9±27.2)%]高于冠心病慢性肾病组[(56.6±27.4)%],差异有统计学意义(P=0.039)。按照ADP受体抑制率、与花生四烯酸途径抑制率临床评价标准,冠心病无慢性肾病组中仅对氯吡格雷不敏感例数[24例(9.4%)]与仅对阿司匹林不敏感例数[25例(9.7%)]比较,差异无统计学意义(P=0.99),冠心病慢性肾病组中仅对氯吡格雷不敏感例数[21例(12.7%)]与仅对阿司匹林不敏感例数[11例(6.6%)]比较,差异有统计学意义(P=0.045)。结论:与单纯冠心病患者相比,冠心病合并慢性肾病时氯吡格雷对血小板抑制率下降,药物敏感性降低。     

奥美拉唑对阿司匹林抗血小板聚集作用的影响研究

目的探讨奥美拉唑对阿司匹林抗血小板聚集作用的影响。方法选择73例稳定型心绞痛患者,随机分为两组:对照组37例,服用阿司匹林肠溶片100mg+安慰剂,1次/d;实验组36例,服用阿司匹林肠溶片100mg+奥美拉唑肠溶片20mg,1次/d。两组均在给药前1d、服药后2周分别测定血小板聚集率。结果对照组及实验组治疗后较治疗前以花生四烯酸(ACA)和腺苷二磷酸(ADP)诱导的血小板聚集率均显著降低(P0.05)。以ACA为诱导剂,实验组治疗后的血小板聚集率(43.7±3.9)%较对照组的(40.2±4.2)%差异无统计学意义(P0.05);以ADP为诱导剂,实验组治疗后的血小板聚集率(76.8±6.7)%较对照组的(72.3±5.6)%差异无统计学意义(P0.05)。结论奥美拉唑对阿司匹林的抗血小板作用无明显影响。     

Personalized Antiplatelet Therapy: Review of the Latest Clinical Evidence

P2Y12-ADP receptor antagonist use has been critical in the development of percutaneous coronary intervention, dramatically reducing the rate of early stent thrombosis. However, it recently was observed that a significant proportion of patients do not achieve optimal platelet reactivity inhibition after clopidogrel loading dose. The large interindividual variability in clopidogrel responsiveness is related to several factors, including the genetic polymorphism of hepatic cytochrome P450 2C19 (CYP2C19*2), which recently has been highlighted by a warning from the U.S. Food and Drug Administration. Of importance, patients exhibiting reduced clopidogrel metabolism and/or low clopidogrel responsiveness (ie, high on-treatment platelet reactivity) have an increased rate of thrombotic events after percutaneous coronary intervention. This review summarizes the current knowledge on this important clinical issue. While the future of genetic testing remains undetermined, several trials are underway to demonstrate the potential utility of platelet reactivity testing with P2Y12-ADP receptor antagonists.     

Clopidogrel Monotherapy After 1-Month Dual Antiplatelet Therapy in Patients With Diabetes Undergoing Percutaneous Coronary Intervention

BackgroundDiabetes was reported to be associated with an impaired response to clopidogrel.ObjectivesThe aim of this study was to evaluate the safety and efficacy of clopidogrel monotherapy after very short dual antiplatelet therapy (DAPT) in patients with diabetes undergoing percutaneous coronary intervention (PCI).MethodsA subgroup analysis was conducted on the basis of diabetes in the STOPDAPT-2 (Short and Optimal Duration of Dual Antiplatelet Therapy After Everolimus-Eluting Cobalt-Chromium Stent–2) Total Cohort (N = 5,997) (STOPDAPT-2, n = 3,009; STOPDAPT-2 ACS [Short and Optimal Duration of Dual Antiplatelet Therapy After Everolimus-Eluting Cobalt-Chromium Stent–2 for the Patients With ACS], n = 2,988), which randomly compared 1-month DAPT followed by clopidogrel monotherapy with 12-month DAPT with aspirin and clopidogrel after cobalt-chromium everolimus-eluting stent implantation. The primary endpoint was a composite of cardiovascular (cardiovascular death, myocardial infarction, definite stent thrombosis, or stroke) or bleeding (TIMI [Thrombolysis In Myocardial Infarction] major or minor) endpoints at 1 year.ResultsThere were 2,030 patients with diabetes (33.8%) and 3967 patients without diabetes (66.2%). Regardless of diabetes, the risk of 1-month DAPT relative to 12-month DAPT was not significant for the primary endpoint (diabetes, 3.58% vs 4.12% [HR: 0.87; 95% CI: 0.56-1.37; P = 0.55]; nondiabetes, 2.46% vs 2.49% [HR: 0.99; 95% CI: 0.67-1.48; P = 0.97]; P_interaction = 0.67) and for the cardiovascular endpoint (diabetes, 3.28% vs 3.05% [HR: 1.10; 95% CI: 0.67-1.81; P = 0.70]; nondiabetes, 1.95% vs 1.43% [HR: 1.38; 95% CI: 0.85-2.25; P = 0.20]; P_interaction = 0.52), while it was lower for the bleeding endpoint (diabetes, 0.30% vs 1.50% [HR: 0.20; 95% CI: 0.06-0.68; P = 0.01]; nondiabetes, 0.61% vs 1.21% [HR: 0.51; 95% CI: 0.25-1.01; P = 0.054]; P_interaction = 0.19).ConclusionsClopidogrel monotherapy after 1-month DAPT compared with 12-month DAPT reduced major bleeding events without an increase in cardiovascular events regardless of diabetes, although the findings should be considered as hypothesis generating, especially in patients with acute coronary syndrome, because of the inconclusive result in the STOPDAPT-2 ACS trial. (Short and Optimal Duration of Dual Antiplatelet Therapy After Everolimus-Eluting Cobalt-Chromium Stent–2 [STOPDAPT-2], NCT02619760; Short and Optimal Duration of Dual Antiplatelet Therapy After Everolimus-Eluting Cobalt-Chromium Stent–2 for the Patients With ACS [STOPDAPT-2 ACS], NCT03462498)