氯吡格雷低反应性与支架内血栓形成的关系

目的探讨氯吡格雷低反应性与冠状动脉支架内血栓的关系,评估氯吡格雷剂量加倍后的疗效。方法连续入选9例经冠状动脉造影确诊的支架内血栓患者为观察组,连续入选100例接受支架植入治疗的冠心病患者为对照组。用光学血小板聚集仪检测花生四烯酸(AA)和二磷酸腺苷(ADP)诱导的血小板聚集率(PLAA和PLADP)。将PLAA>20%、PLADP>40%分别定义为阿司匹林和氯吡格雷低反应性,对观察组氯吡格雷低反应者加倍剂量至150mg/d,随访PLADP及临床事件。结果观察组氯吡格雷低反应的发生率高于对照组(100%vs.27%)(P<0.01);观察组PLADP水平显著高于对照组[(53.6±6.3)%vs.(31.9±14.0)%](P<0.01);观察组氯吡格雷剂量加倍后,血小板聚集率显著降低[(53.6±6.3)%vs.(37.0±10.9)%](P<0.01)。观察组与对照组均未检出阿司匹林低反应患者。结论氯吡格雷低反应性是冠状动脉支架内血栓形成的危险因素。氯吡格雷剂量加倍可显著降低残余血小板聚集率,可能减少支架内血栓形成事件的发生。     

氯吡格雷与质子泵抑制剂合用对亚急性支架内血栓形成的影响

目的探讨氯吡格雷与质子泵抑制剂(PPIs)合用对PCI术后1个月内亚急性支架内血栓形成的影响。方法观察6 209例PCI术后接受氯吡格雷治疗的患者,分为使用PPIs组(1 182例)及未使用PPIs组(5 027例)。比较两组PCI术后1个月内亚急性支架内血栓发生情况,分析氯吡格雷与PPIs合用对亚急性支架内血栓形成的影响。结果两组患者的一般资料、相关检查化验、合并用药及冠脉病变等比较差异无统计学意义(P>0.05)。发生亚急性支架内血栓形成情况:未使用PPIs组34例(0.68%),使用PPIs组4例(0.37%),两组比较差异无统计学意义(χ2=1.797,P=0.18)。结论 PCI术后1个月内接受氯吡格雷联合PPIs治疗,未观察到有增加亚急性支架内血栓形成的风险。     

Pathobiology of stent thrombosis after drug-eluting stent implantation

First generation drug-eluting stents (DES) have significantly improved the treatment options for patients with symptomatic coronary artery disease by decreasing rates of acute vessel closure and restenosis after percutaneous coronary revascularization procedures. However, early enthusiasm was temperd by reports of late stent thrombosis (LST), which raised concerns about safety. Since millions of DES have been implanted in patients worldwide, it is imperative to understand the pathology of DES in man. Autopsy studies from the CVPath DES registry documented that delayed arterial healing is accompanied by poor endothelialization of stent struts which is the single best predictor of late stent thrombosis. Arterial healing of DES is highly heterogeneous and is dependent on underlying plaque morphology as well as on the stent location. We identified several anatomical and pathological changes in man, which were associated with LST; these include hypersensitivity reaction to polymer, plaque rupture, bifurcation sites, malapposition and stent fracture. DES was also associated with premature atherosclerotic changes versus BMS.     

氯吡格雷基因多态性与血栓弹力图相关性研究

目的:通过探讨CPY2C19基因多态性与抗血小板活性的相关性,明确中国人群冠心病患者中CPY2C19基因多态性与血栓弹力图相关性,提出个体化给药建议,确保患者疗效,提升临床药学学科服务水平。方法:临床药师按照患者的疾病诊断、现病史以及主诉等进行初步入组100名冠心病患者,通过药师工作站等工作平台实时跟踪患者的抗血小板治疗方案的调整,并在日常床旁问诊中了解患者的抗血小板治疗效果。对于确定入组的患者应跟踪并详细记录其血栓弹力图以及CYP2C19基因型的测定结果,以便后期确定氯吡格雷相关基因多态性在冠心病患者中的分布规律以及氯吡格雷相关基因型与剂量调整及血小板聚集率的相关性。结果:100例入组患者,慢代谢型有16例,占16%,中间代谢型36%,快代谢型为48%。在45例患者血栓弹力图中,ADP抑制率不达标者占62.2%(28/45)。结论:临床药师与临床医师应根据血栓弹力图与CYP2C19的基因测定相结合,最终确定患者的个体化抗血小板治疗方案。建议冠心病患者应尽快进行氯吡格雷基因型测定,在治疗期间可根据临床疗效适当进行血栓弹力图进行抗血小板活性验证。     

不同维持剂量氯吡格雷对氯吡格雷抵抗急性冠状动脉综合征患者的有效性及安全性研究

目的探讨对于冠状动脉介入治疗的氯吡格雷低反应的急性冠状动脉综合征(ACS)患者,能否通过增加氯吡格雷维持剂量来降低血小板聚集率,改善临床预后,从而为氯吡格雷低反应的ACS患者围手术期药物选择提供依据。方法选择诊断为ACS并行经皮冠状动脉介入治疗(PCI)的氯吡格雷低反应患者208例。随机分为2组,A组(常规剂量组)PCI术前给予600mg氯吡格雷负荷量,术后给予75mg氯吡格雷维持剂量至少1年;B组(双倍剂量组)PCI术前给予600mg氯吡格雷负荷量,术后给予150mg氯吡格雷维持剂量30d,以后继续给予75mg氯吡格雷维持剂量至少1年。1血小板聚集率测定:测定各组患者入院时的基础血小板聚集率及氯吡格雷600mg负荷量用药4h、维持量氯吡格雷用药后7、14、30、90、180d的血小板聚集率。2临床随访:所有患者均在180d内进行随访,观察不同维持剂量组主要心脏不良事件(MACE)事件和出血事件的发生率。结果 12组患者维持量氯吡格雷用药后7d的血小板聚集率差异无统计学意义;14、30、90、180d的血小板聚集率双倍剂量组较常规剂量组显著降低,差异有统计学意义。2随访180d结果显示双倍剂量组较常规剂量组MACE事件发生率有所减少,但是差异无统计学意义;2组出血事件发生率差异也无统计学意义。结论 PCI术后应用150mg氯吡格雷维持剂量与常规氯吡格雷维持剂量相比,可进一步降低氯吡格雷低反应患者的血小板聚集率,但是MACE事件发生率无明显降低,且不增加出血事件的发生率。     

氯吡格雷在经皮冠状动脉支架成形术围术期的运用

目的 :报告血小板 ADP受体拮抗剂氯吡格雷 (clopidogrel,plavix)在经皮冠状动脉支架成形术围术期运用的方法和结果。方法 :接受经皮冠状动脉支架成形术患者 2 1例 ,术前给予氯吡格雷负荷量 45 0 mg,顿服或 75 mg 2次 / d× 3 d,术后 75 mg 1次 / d× 3 0 d。同时联合应用阿司匹林、GPIlb/ IIIa拮抗剂 integrilin和肝素等其它抗凝和抗血小板药物。常规检测激活凝血时间(ACT)、凝血酶原时间 (PT)和部分凝血酶原时间 (KPTT) ,如果 ACT≤ 15 0 s,则拔除鞘管。出院前和术后 1个月复查血常规 1次。同时记录有无皮疹等副反应。结果 :所有患者均在术后 2～ 4h拔除鞘管 ,无穿刺部位显著血肿形成者 ,无冠状动脉急性和亚急性血栓形成者。 9例术后随访 1年、12例随访 1月无负性心脏事件发生 ,其中 5例复查冠脉造影阴性。全部患者术后血小板、白细胞无显著改变。未发现皮疹等不良反应。结论 :氯吡格雷在经皮冠状动脉支架成形术围术期运用 ,不良反应少 ,联合阿司匹林和 integrilin,是一种安全有效的方法 ,可减少急性、亚急性支架内血栓形成 ,进而可降低支架内再狭窄率     

阿司匹林、噻氯匹啶、低分子量肝素预防亚急性冠状动脉支架血栓形成

目的　观察阿司匹林、噻氯匹啶、低分子量肝素预防亚急性冠脉支架血栓形成 (SST)的效果。方法　 67例成功植入冠状动脉内支架的病人随机分成两组 ,治疗组 34例 (男 30例 ,女 4例 ,年龄 62± 5岁 ) ,对照组 33例 (男 30例 ,女 3例 ,年龄 61± 4岁 )。所有病人术前 3d均接受阿司匹林 30 0mg ,每日 1次 ,噻氯匹啶 2 50mg ,每日 1次 ,术后次日口服阿司匹林 30 0mg,每日 1次 ,噻氯匹啶 2 50mg,每日 2次 ,共 1个月。术后治疗组拔管后即予低分子量肝素 0 6ml,每 1 2h一次腹壁皮下注射 ,连续 3d。对照组拔管后 1h给予普通肝素 750～ 1 2 50IU/h持续静脉泵输入 ,连续 3d ,并根据ACT调整肝素剂量。结果　随访 2周 ,两组未见出现SST ,但治疗组出血并发症明显少于对照组 (P <0 0 5) ,且使用简便。结论　阿司匹林、噻氯匹啶、低分子量肝素预防亚急性冠脉支架血栓形成安全有效     

氯吡格雷对冠状内支架置入术后预后的影响

目的 观察冠脉支架置入术后应用氯吡格雷(抗血小板药)加阿司匹林的抗血小板聚集作用及其安伞性.方法 67例经皮冠状动脉内支架置入术治疗冠心病患者,随机分为试验组(36例)和对照组(3l例):对照组,支架置入术后,继续服用阿司匹林和氯吡格雷9～12个月;试验组,此后继续服用阿司匹林和氯吡格雷18～24个月.观察2组主要心血管事件和出血并发症的发生情况.结果 2组患者主要心血管事件的发生率比较,差异有统计学意义(P<0.05);出血并发症的发生率比较,差异无统计学意义(P>0.05).结论 经皮冠状动脉内支架置入术后应用氯吡格雷加阿司匹林,应用时间越长,其主要心血管事件发生越少且出血并发症的发生率并无增加.     

Role of stent design and coatings on restenosis and thrombosis

More than 15 years have passed since stent technology was introduced by Sigwart et al. [U. Sigwart, J. Puel, V. Mirkovitch, F. Joffe, et al. Intravascular stents to prevent occlusion and restenosis after transluminal angioplasty. N. Engl. J. Med. 316 (1987) 701-706.] among interventional cardiologists. Recently drug eluting stents have assumed dominance in the interventional world as positive trial results revealed their efficacy for preventing restenosis. Stent design, delivery-vehicle materials, and drug properties affect the function of these stents. Stainless steel stents with tubular and multicellular design have proven superior to coil or hybrid stent models. This chapter describes stents which have subtle influences of modular design, metal coverage, strut thickness, strut shape, surface smoothness, and coating materials like an alloy composition.     

阿司匹林联合氯吡格雷治疗脑血栓的效果观察

目的 分析针对脑血栓患者实施阿司匹林联合氯吡格雷治疗的效果.方法 120例脑血栓患者,按照治疗方案不同分为对照组和观察组,每组60例.两组患者均接受常规治疗,在此基础上,对照组患者应用阿司匹林治疗,观察组患者应用阿司匹林联合氯吡格雷治疗.比较两组患者治疗后生活质量评分及治疗效果.结果 治疗后,观察组患者躯体疼痛、总体健...     

不同负荷剂量氯吡格雷对植入药物洗脱支架患者术后影响

目的 探讨药物洗脱支架(DES)植入后予不同剂量氯吡格雷的安全性及术后主要不良心脏事件(MACE).方法 176例接受DES植入患者随机进入氯吡格雷300、450、600、750 mg负荷剂量组,术前6～24 h服药,服药前及服药后4、24、48 h监测血小板聚集率(PA),服药前、后24 h监测血小板计数.临床随访6个月.结果 氯吡格雷600、750 mg组PA抑制明显,维持时间长,发生氯吡格雷抵抗病例少,MACE发生少; 严重出血事件各组之间无差别,600、750 mg组轻微出血事件增高,750 mg组血小板计数明显下降.结论 600、750 mg组抑制PA效果更明显,作用时间更长,MACE发生更少; 600 mg负荷剂量优势更明显.     

PCI后晚期血栓合并冠脉痉挛

目的探讨PCI后晚期支架血栓合并冠脉痉挛发生冠脉＂激惹现象＂的处理。方法采用PCI方法对一名45岁男性非ST段抬高非Q波性急性下壁心肌梗死患者实施支架治疗后一个月,再次冠脉造影发现支架血栓合并冠脉痉挛,并再次PCI处理中发生冠脉＂激惹现象＂。结果支架内血栓经PT-CA处理和术后抗血小板治疗好转,冠脉痉挛应用硝酸甘油和维拉帕米无效,经多次PTCA后植入支架,效果满意。结论 PCI和应用药物是处理晚期支架内血栓合并冠脉痉挛的有效方法,冠脉＂激惹＂的处理要慎重。     

Platelet hyperreactivity and stent thrombosis in patients undergoing coronary stenting

Stent thrombosis (ST) is a rare but very serious event complicating percutaneous coronary intervention (PCI) procedures. Both procedure- and patient-related factors, including inadequate platelet inhibition are well known predictors of ST. According to the present guidelines, a dual antiplatelet treatment regimen consisting of aspirin and a P2Y12 receptor inhibitor such as clopidogrel, prasugrel or ticagrelor is routinely administered to ACS patients and to patients undergoing PCI in order to prevent thrombotic vessel occlusions. In recent years, evidence has grown that patients showing high on-treatment platelet reactivity (HPR) under clopidogrel intake exhibit a higher risk for the occurrence of ischemic events including ST. For assessing HPR, different platelet function assays are currently available and have already found their way into routine clinical practice in several centers. Along with this development, more potent P2Y12 receptor inhibitors like prasugrel and ticagrelor are substitutes for clopidogrel in specific circumstances such as in ACS patients or in patients who do not adequately respond to standard clopidogrel treatment. Utilizing platelet function monitoring, patients showing HPR can be identified and an optimized antiplatelet treatment regime can be tailored for these patients. This review paper aims to summarize the important facts in relation to ST and antiplatelet therapy with a particular focus on P2Y12 receptor inhibition and its ex vivo assessment in patients undergoing coronary stent placement.     

A risk scoring system to predict coronary stent thrombosis

Objective: Stent thrombosis (ST) is a potentially life-threatening complication of percutaneous coronary intervention (PCI). We aimed to develop a scoring system to predict the risk of ST following PCI.

Research design and methods: Odds ratios (ORs) for risk factors associated with ST were identified from a meta-analysis based on a systematic literature review, and through consensus expert opinion (Delphi–RAND method). The combined ORs were used to calculate risk scores for acute (within 24?hours), early (within 30 days) and late (31 days to 1 year) ST. Risk scores were validated against patient-level data from the TRITON-TIMI 38 study. Twenty risk factors were identified.

Results: The most highly predictive factor for early and late ST was “incomplete duration of dual antiplatelet therapy”. Derived total risk scores ranged from 0 to 22 for acute and early ST, and from 0 to 20 for late ST. Increasing scores were associated with an increasing risk of ST when applied to trial data. Model discrimination was 0.60 (p?=?.0028), 0.67 (p?p?Conclusion: Our weighted scoring system may help to stratify ST risk and individualize antiplatelet therapy in patients undergoing PCI.     

国产BuMA支架术后支架血栓及主要临床事件随访分析

目的 探讨植入国产生物降解药物涂层冠状动脉Bu MA支架治疗冠心病的远期安全性及有效性。方法选择同期植入Bu MA支架及Resolute支架的冠心病患者分别作为观察组(440例)和对照组(460例),2组临床基线情况、冠脉造影(CAG)病变情况及经皮冠脉介入治疗(PCI)相关指标均无明显差别。对患者进行平均(24±4)个月随访,随访主要终点事件为发生明确的或很可能的支架血栓(ST);次要终点事件为主要心脏不良事件(MACEs),包括再发心绞痛、急性非致死性心肌梗死、死亡、靶血管血运重建(TVR)的复合终点;其他终点事件为全因死亡、心源性死亡、心肌梗死(MI)、靶病变血运重建(TLR)、非靶血管血运重建及卒中。观察组失访5例,对照组失访26例。结果观察组435例患者共植入615枚支架,对照组434例患者共植入614枚支架,2组均平均植入1.41枚/例。2组主要终点[1.4%(6/435)vs 1.8%(8/434),χ2=0.087]、次要终点[12.3%(54/435)vs 10.8%(47/434),χ2=0.524]及其他终点事件发生率的差异均无统计学意义。结论 国产Bu MA支架具有良好的远期安全性及有效性。