Pexelizumab for acute ST-elevation myocardial infarction in patients undergoing primary percutaneous coronary intervention: a randomized controlled trial

Context  Reperfusion with percutaneous transluminal coronary intervention (PCI) is effective at improving outcomes in patients with acute ST-elevation myocardial infarction (STEMI). However, in patients without prompt reestablishment of brisk coronary flow and tissue perfusion, mortality remains high, providing an opportunity for novel treatments, including anti-inflammatory agents. Objective  To evaluate the effectiveness of pexelizumab, a humanized monoclonal antibody that binds the C5 component of complement, as an adjunct to PCI in improving 30-day mortality from STEMI. Design, Setting, and Patients  This trial was a prospective, multicenter, double-blind, placebo-controlled, phase 3 study of the intravenous administration of pexelizumab in conjunction with primary PCI in STEMI with prespecified high-risk electrocardiographic findings. The trial was intended to enroll 8500 patients, but in conjunction with the US Food and Drug Administration enrollment was modified to 5745 patients presenting from 296 hospitals in 17 countries from July 13, 2004, to May 11, 2006. Interventions  Two thousand eight hundred eighty-five patients were randomly assigned to receive placebo and 2860 to receive pexelizumab given as a 2-mg/kg intravenous bolus prior to PCI followed by 0.05-mg/kg per hour infusion over the subsequent 24 hours. Patients were randomized within 6 hours of symptom onset. Main Outcome Measures  The primary end point was all-cause mortality through day 30. Secondary end points were death through day 90 and the composite of death, cardiogenic shock, or congestive heart failure through days 30 and 90. Results  No difference in mortality through day 30 was observed between the pexelizumab and placebo treatment groups, with 116 patients (4.06%) and 113 patients (3.92%) who died in the respective groups (hazard ratio [HR], 1.04; 95% confidence interval [CI], 0.80-1.35; log-rank P = .78). The composite end points of death, shock, or heart failure were also similar with 257 patients (8.99%) receiving pexelizumab and 265 patients (9.19%) receiving placebo at 30 days (HR, 0.98; 95% CI, 0.83-1.16; P = .81) and 293 patients (10.24%) receiving pexelizumab and 293 patients (10.16%) receiving placebo at 90 days (HR, 1.01; 95% CI, 0.86-1.19; P = .91). Conclusion  In this large clinical trial of patients treated with primary PCI for STEMI, mortality was low and unaffected by administration of pexelizumab. Trial Registration  clinicaltrials.gov Identifier: NCT00091637      

冠心病患者PCI后 应用氯吡格雷治疗发生出血事件的相关因素研究

目的 探讨冠心病患者实施经皮冠状动脉介入术(PCI)后长期应用氯吡格雷治疗发生出血事件的危险因素.方法 选取2014年1月至2016年3月大连大学附属中山医院循环二科实施PCI治疗的冠心病患者224例,所有患者术后均常规服用氯吡格雷治疗,对患者均进行了6个月的追踪观察,按照患者是否发生出血事件分为出血组47例、非出血组177例,比较两组各项临床资料.结果 冠心病患者PCI术后服用氯吡格雷发生出血事件的独立危险因素为合并高血压、饮酒、消化道溃疡病史、入院诊断为急性冠状动脉综合征(ACS)(OR值分别为1.527、1.908、2.246、1.803,P<0.05).结论 冠心病患者实施PCI后长期应用氯吡格雷治疗发生出血事件的危险因素合并高血压、饮酒、消化道溃疡病史、入院诊断为ACS.     

Omeprazole affects clopidogrel efficacy but not ischemic events in patients with acute coronary syndrome undergoing elective percutaneous coronary intervention

Background  Omeprazole, usually used in the antiplatelet therapy during percutaneous coronary intervention (PCI) in acute coronary syndrome (ACS), has been reported to increase ischemic events in retrospective studies. However, other clinical trials gave paradoxical results. The aim of this study was to assess the effects of omeprazole on clopidogrel efficacy and clinical events.

Methods  All patients (n=172) received aspirin (loading dose 300 mg and maintenance dose 100 mg/d) and clopidogrel (loading dose 600 mg and maintenance dose 75 mg/d) during the therapy. They were randomized to receive omeprazole (20 mg/d) or placebo for 30 days. Residual platelet activities in the adenosine 5′-diphosphate (ADP) pathway were detected on the fifth day after PCI with thrombelastography (TEG)-mapping. The clinical events were recorded after one month.

Results  According to the five levels of platelet activities, the frequency distributions of the inhibition rates were significantly different (P=0.0062). However, no significant change was seen in the distribution among the highest or the lowest inhibiting levels (>95% and <30% inhibition rate). And there were no significant differences (P >0.05) in events incidence, while gastra-intesternal bleeding decreased in co-administration of omeprazole.

Conclusions  Omeprazole significantly blunts clopidogreal efficacy while not exacerbates ischimic events in ACS undergoing PCI. Omeprazaole even can decrease gastra-intestinal bleeding in those patients.

     

Thorombolytic therapy with rescue percutaneous coronary intervention versus primary percutaneous coronary intervention in patients with acute myocardial infarction: a multicenter randomized clinical trial

Background Although thrombolytic therapy with rescue percutaneous coronary intervention （PCI） is a common treatment strategy for ST-segment elevation acute myocardial infarction （STEMI）, scant data are available on its efficacy relative to primary PCI, and comparison was therefore the aim of this study. Methods This multicenter, open-label, randomized, parallel trial was conducted in 12 hospitals on patients （age 〈70 years） with STEMI who presented within 12 hours of symptom onset （mean interval 〉3 hours）. Patients were randomized to three groups： primary PCI group （n=101）; recombinant staphylokinase （r-Sak） group （n=-104）; and recombinant tissue-type plasminogen activator （rt-PA） group （n=-106）. For all patients allocated to the thrombolytic therapy arm, coronary angiography was performed at 90 minutes after drug therapy to confirm infarct-related artery （IRA） patency; rescue PCI was performed in cases with TIMI flow grade 〈2. Bare-metal stent implantation was planned for all patients. Results After randomization it required an average of 113.4 minutes to start thrombolytic therapy （door-to-needle time）and 141.2 minutes to perform first balloon inflation in the IRA （door to balloon time）. Rates of IRA patency （TIMI flow grade 2 or 3） and TIMI flow grade 3 were significantly lower in the thrombolysis group at 90 minutes after drug therapy than in the primary PCI group at the end of the procedure （70.5% vs. 98.0%, P 〈0.0001, and 53.0% vs. 85.9%, P 〈0.0001, respectively）. Rescue PCI with stenting was performed in 117 patients （55.7%） in the thrombolytic therapy arm. Rates of patency and TIMI flow grade 3 were still significantly lower in the rescue PCI than in the primary PCI group （88.9% vs. 97.9%, P=-0.0222, and 68.4% vs. 85.0%, P=0.0190, respectively）. At 30 days post-therapy, mortality rate was significantly higher in the thrombolysis combined with rescue PCI group than in primary PCI group （7.1% vs. 0, P=0.0034）. Rates of death/MI and bleeding complications were significantly higher in the thrombolysis with rescue PCI group than in the primary PCI group （10.0% vs. 1.0%, P=-0.0380, and 28.10% vs. 8.91%, P=-0.O001, respectively）. Conclusions Thrombolytic therapy with rescue PCI was associated with significantly lower rates of coronary patency and TIMI flow grade 3, but with significantly higher rates of mortality, death/MI and hemorrhagic complications at 30 days, as compared with primary PCI in this group of Chinese STEMI patients with late presentation and delayed treatments.     

经皮冠状动脉介入治疗术后出现氯吡格雷抵抗患者的治疗方案选择

目的:探讨经皮冠状动脉介入治疗(percutaneous coronary intervention,PCI)术后出现氯吡格雷抵抗患者换用双倍剂量氯吡格雷和替格瑞洛治疗的有效性及安全性?方法:选取PCI术后出现氯吡格雷抵抗(血小板抑制率<30%)患者188例,随机分为氯吡格雷常规剂量组(A组,64例)?氯吡格雷双倍剂量组(B组,61例)?替格瑞洛组(C组,63例),术后7 d分别检测二磷酸腺苷(adenonisine disphosphate,ADP)通道的血小板抑制率?术后1 d及7 d检测超敏C反应蛋白(high sensitivity C reactive protein,hsCRP),观察术后1个月及6个月时主要心脏不良事件(major adverse cardiovascular events,MACE)及轻度出血发生率?结果:术后7 d检测ADP通道的血小板抑制率,B组及C组血小板抑制率明显升高,和A组相比差异有统计学意义(P < 0.05);且C组血小板抑制率高于B组(P < 0.05)?术后1 d检测hsCRP,3组结果差异无统计学意义,术后7 d检测hsCRP,B组及C组均明显降低,和A组相比差异有统计学意义(P < 0.05);相比B组,C组hsCRP降低更明显(P < 0.05)?随访至术后1个月,3组之间MACE及轻度出血发生率无明显差异(P > 0.05);随访至术后6个月时,B组及C组MACE发生率均显著低于A组,差异有统计学意义(P < 0.05),且C组MACE发生率低于B组(P < 0.05),但3组之间轻度出血发生率差异仍无统计学意义(P > 0.05)?结论:PCI术后出现氯吡格雷抵抗患者,选用替格瑞洛治疗具有更好的有效性,且不增加不良反应?     

超负荷量氯吡格雷对急诊经皮冠脉介入治疗患者围术期的影响

目的:对比研究拟行急诊冠脉介入治疗(PCI)患者术前服用超负荷量氯吡格雷(600 mg)与常规负荷量(300 mg)预处理的近期疗效及安全性。方法:选择2007年1月至2009年12月行急诊PCI治疗的急性心肌梗死患者60例,随机分为常规负荷量组(300 mg,n=30)和超负荷量组(600 mg,n=30),入院后两组立即分别服用氯吡格雷300 mg和600 mg。观察术后28天内主要临床心血管事件(包括亚急性支架内血栓形成、死亡、心肌梗死、紧急靶血管血运重建)和出血事件。结果:氯吡格雷600 mg组28天主要心血管事件发生率较300 mg组显著减少(3.3%vs 20.0%,P<0.05),而两组28天出血事件发生率无显著差异(20.0%vs13.3%,P>0.05)。结论:超负荷量氯吡格雷(600 mg)预治疗与常规负荷量(300 mg)相比,可显著改善急性心肌梗死行急诊PCI患者的近期疗效,且安全性相似。     

左卡尼汀治疗急性心肌梗死PCI术后患者的临床观察

目的:观察急性心肌梗死(AMI)经皮冠状动脉介入治疗(PCI)术后予以左卡尼汀治疗的临床疗效。方法:在我院住院的60例急性心肌梗死行PCI术后的患者,随机分为观察组和对照组,对照组予以抗凝及抗缺血治疗,观察组在常规治疗的基础上加用左卡尼汀。检测术前及术后肌酸激酶同工酶(CK-MB)、心肌肌钙蛋白T(cTnT)、脑钠肽(BNP)水平,术前及术后2周心脏B超检查。结果:左卡尼汀组CK-MB、cTnT及血浆BNP水平较对照组下降明显,差异有统计学意义(P<0.05);心脏指数(CI)、左室射血分数(LVEF)治疗后均较对照组有明显改善,差异具有统计学意义(P<0.05)。结论:左卡尼汀对心肌具有保护作用,对急性心肌梗死PCI术后的患者使用具有重要的临床意义。     

冠心病PCI术后发生氯吡格雷抵抗的影响因素

目的 分析接受经皮冠状动脉介入(PCI)治疗的冠心病患者服用双联抗血小板药物后发生氯吡格雷抵抗的影响因素.方法 181例接受PCI治疗的冠心病患者服用阿司匹林和氯吡格雷双联抗血小板药物治疗,术后3d晨起空腹接受血栓弹力图检查,根据对二磷酸腺苷诱导的血小板聚集抑制率的测定结果分为氯吡格雷抵抗组和氯吡格雷敏感组,比较两组患者的一般临床资料、生化指标和影像学特征,Logistic回归分析氯吡格雷抵抗的独立危险因素.结果 181例患者氯吡格雷抵抗的发生率为33.1％(60/181).两组患者的性别构成比、吸烟史、糖尿病史、空腹血糖、糖化血红蛋白、三酰甘油和心肌肌钙蛋白I(cTnI)的差异均有统计学意义(P＜0.05),两组患者影像学检查各项参数比较差异无统计学意义(P＞0.05).Logistic回归分析结果显示氯吡格雷抵抗的独立危险因素有女性(P=0.004,OR=3.411,95％ CI=1.466～ 7.940)、吸烟史(P=0.033,OR =4.930,95％ CI=1.137 ～21.371)、糖尿病史(P=0.007.OR=3.226,95％ CI=1.378 ～7.551)、高空腹血糖(P =0.028,OR=2.113,95％ CI=1.082 -4.125)、高糖化血红蛋白(P=0.000.OR =3.744,95％ CI=1.868 ～7.505)、高三酰甘油(P=0.019,OR=2.639,95％ CI=1.173 ～5.937)和高cTnI(P=0.000,OR=5.631,95％ CI -2.942 ～ 10.777).结论 女性、糖尿病、吸烟、高血脂和心肌酶增高可能是冠心病患者PCI术后发生氯吡格雷抵抗的危险因素.     

冠脉支架术后长期联用阿司匹林和氯吡格雷的有效性与安全性研究

目的观察急性冠脉综合征冠脉支架术后联合应用阿司匹林和氯吡格雷的疗效及安全性。方法将行冠脉支架术的611例冠心病患者按病情分为急性冠脉综合征组（ACS,72=424）和稳定性心绞痛组（SAP,n=187）。两组在冠脉支架术后长期联合应用（最短1个月,31．8％超过12个月）阿司匹林和氯吡格雷至随访结束。比较两组联合应用抗血小板的情况,观察两组患者主要心血管事件（心血管性死亡、心肌梗死、心肌缺血复发进行靶血管再通治疗）及抗血小板副作用（消化道出血、血小板减少、白细胞减少）的发生率。结果急性冠脉综合征组发生76例心血管事件（死亡15例,心肌梗死10例、靶血管再通治疗45例,卒中6例）;稳定性心绞痛组发生25例心血管事件（心血管性死亡8例,心肌梗死1例,靶血管再通治疗14例,卒中2例）,组间差异无显著性（P〉0．05）;阿司匹林及氯吡格雷负荷量差异有显著性,联合应用超过12个月例数差异无显著性意义;两组抗血小板副作用（消化道出血、血小板减少、白细胞减少）的发生率间差异无显著性（P〉0．05）。结论急性冠脉综合征组冠脉支架术后长期联合应用阿司匹林和氯吡格雷安全、有效,可减少冠脉支架术后心血管事件的发生,出血、血小板减少、白细胞减少等抗血小板药物并发症无明显增加。     

双倍剂量氯吡格雷对冠心病支架植入术后氯吡格雷低反应患者的疗效及安全性研究

目的:评估双倍剂量氯吡格雷强化抗栓1个月与常规剂量相比对冠心病经皮冠状动脉支架植入(percutaneous coronary intervention,PCI)术后氯吡格雷低反应性(clopidogrel low response,CLR)患者血小板聚集功能的影响及安全性?方法:将冠心病PCI术后通过光学血小板聚集仪检测发现的CLR患者92例随机分为常规剂量组与双倍剂量组,观察两组患者1个月后血小板聚集功能的变化并随访1年的临床预后及安全性?结果:在住院期间两组患者的二磷酸腺苷诱导的血小板聚集率(adenosine diphosphate induced platelet aggregation,PLADP)无显著差异(P > 0.05);但在1个月随访时双倍剂量组的PLADP显著低于常规剂量组(P < 0.001);1年随访主要不良事件在两组间的发生率均为4.3%?常规剂量组的次要不良事件发生率高于双倍剂量组,主要表现为心源性再入院率显著高于双倍剂量组(P < 0.01)?双倍剂量组大出血(0% vs. 0%)?小出血(0% vs. 0%)?轻微出血(10.9% vs. 10.9%)的发生率与常规剂量组相当?结论:与常规剂量组相比,双倍剂量氯吡格雷强化抗栓1个月能显著降低氯吡格雷低反应患者的血小板聚集率,显著降低1年随访的心源性再入院率,且未增加出血风险?     

氯吡格雷对非ST段抬高急性冠脉综合征患者PCI术后高敏C反应蛋白的影响及预后评价

目的:观察对于非ST段抬高性急性冠脉综合征(NSTEACS)患者行择期经皮冠脉介入(PCI)治疗,增加氯吡格雷的维持剂量能否进一步降低高敏C反应蛋白(hs-CRP)浓度,并影响临床预后。方法:选取100例择期行药物洗脱支架(DES)植入术的NSTEACS患者,随机分为高维持量组(n=50)和常规剂量组(n=50),术后分别给予氯吡格雷150 mg/d及75 mg/d治疗,7 d后两组均以标准剂量维持。分别于术前及服药7 d时测定患者的hs-CRP浓度,并随访比较术后7 d和30 d时两组之间心脏主要不良事件及出血的发生情况。结果:(1)两组的基本临床特征、术前hs-CRP浓度之间的差异均无统计学意义。(2)服药7 d时高维持剂量组的hs-CRP下降程度显著高于标准维持剂量组(P=0.005)。(3)术后7 d时随访,两组在联合终点事件、术后缺血性事件及出血事件发生率的差异均无统计学意义。术后30 d随访,氯吡格雷高维持剂量组较标准维持剂量组显著减少临床心脏不良事件,而且不增加出血的发生率。结论:增加氯吡格雷维持剂量可以显著降低NSTEACS患者PCI术后hs-CRP浓度,显著改善患者短期预后,具有较好的安全性。     

Effect of clopidogrel pretreatment before percutaneous coronary intervention in patients with ST-elevation myocardial infarction treated with fibrinolytics: the PCI-CLARITY study

Context  The benefit of clopidogrel pretreatment before percutaneous coronary intervention (PCI) remains debated and its use has not been universally adopted. Objective  To determine if clopidogrel pretreatment before PCI in patients with recent ST-segment elevation myocardial infarction (STEMI) is superior to clopidogrel treatment initiated at the time of PCI in preventing major adverse cardiovascular events. Design, Setting, and Participants  The PCI-Clopidogrel as Adjunctive Reperfusion Therapy (CLARITY) study was a prospectively planned analysis of the 1863 patients undergoing PCI after mandated angiography in CLARITY–Thrombolysis in Myocardial Infarction (TIMI) 28, a randomized, double-blind, placebo-controlled trial of clopidogrel in patients receiving fibrinolytics for STEMI. Patients were enrolled at 319 sites in 23 countries from February 2003 through October 2004. Interventions  Patients received aspirin and were randomized to receive either clopidogrel (300 mg loading dose, then 75 mg once daily) or placebo initiated with fibrinolysis and given until coronary angiography, which was performed 2 to 8 days after initiation of the study drug. For patients undergoing coronary artery stenting, it was recommended that open-label clopidogrel (including a loading dose) be administered after the diagnostic angiogram. Main Outcome Measures  The primary outcome was the incidence of the composite of cardiovascular death, recurrent MI, or stroke from PCI to 30 days after randomization. Secondary outcomes included MI or stroke before PCI and the aforementioned composite from randomization to 30 days. Results  Pretreatment with clopidogrel significantly reduced the incidence of cardiovascular death, MI, or stroke following PCI (34 [3.6%] vs 58 [6.2%]; adjusted odds ratio [OR], 0.54 [95% CI, 0.35-0.85]; P = .008). Pretreatment with clopidogrel also reduced the incidence of MI or stroke prior to PCI (37 [4.0%] vs 58 [6.2%]; OR, 0.62 [95% CI, 0.40-0.95]; P = .03). Overall, pretreatment with clopidogrel resulted in a highly significant reduction in cardiovascular death, MI, or stroke from randomization through 30 days (70 [7.5%] vs 112 [12.0%]; adjusted OR, 0.59 [95% CI, 0.43-0.81]; P = .001; number needed to treat = 23). There was no significant excess in the rates of TIMI major or minor bleeding (18 [2.0%] vs 17 [1.9%]; P>.99). Conclusions  Clopidogrel pretreatment significantly reduces the incidence of cardiovascular death or ischemic complications both before and after PCI and without a significant increase in major or minor bleeding. These data add further support to the early use of clopidogrel in STEMI and the strategy of routine clopidogrel pretreatment in patients undergoing PCI.      

急性冠脉综合征介入治疗后冠状动脉支架内血栓临床分析

目的探讨冠状动脉支架置入术后支架内血栓形成的临床特点及治疗措施。方法回顾性分析273例急性冠脉综合征（ACS）患者中冠状动脉支架术后4例支架内急性和亚急性血栓患者的临床及冠状动脉造影特点,并评价其治疗方法的疗效。结果因ACS在兰州大学第一医院行直接或补救性PCI患者273例中4例在PCI术后3～66h发生冠状动脉内血栓形成,支架内血栓形成后多数患者出现典型的临床表现及心电图改变,行急诊冠状动脉造影复查证实原支架内完全血栓性闭塞,急诊经皮冠状动脉介入治疗,2例患者治愈存活出院,2例患者抢救无效死亡。结论支架内亚急性血栓形成的原因是多方面的,主要与血管病变特点,支架长度及帖壁情况,抗凝、抗血小板是否充分有关。急诊再次介入治疗是治疗支架内血栓形成的首选治疗方案,尽早实施急诊经皮冠状动脉介入治疗可增加抢救成功率。     

替格瑞洛用于急性冠脉综合征患者经皮冠状动脉介入治疗的疗效及安全性

【摘要】 目的 研究替格瑞洛对急性冠脉综合征（ACS）患者血小板抑制率及主要心脏不良事件的影响。方法 将2014年9月～2015年12月期间的51例经皮冠状动脉介入治疗（PCI）术后使用替格瑞洛治疗的ACS病人作为观察组,同时期使用氯吡格雷治疗的行PCI手术的ACS患者51例作为对照组,比较两组治疗后二磷酸腺苷（ADP）诱导的血小板抑制率、主要心脏不良事件发生率以及出血、呼吸困难发生率。结果 治疗后1周及1个月,观察组的血小板抑制率明显高于对照组,组间差异有显著性（P＜005）;观察组主要心脏不良事件发生率明显低于对照组,组间差异亦有显著性（P＜005）。结论 替格瑞洛用于行PCI术的ACS病人中,抗血小板效果显著,且能降低主要心脏不良事件的发生率,安全性良好。     

急性冠状动脉综合征介入术前应用他汀类药物强化治疗的疗效观察

目的 探讨急性冠状动脉综合征(ACS)介入术前应用他汀类药物强化降脂对患者血清C反应蛋白(CRP)及血脂水平的影响.方法 将2010年5月～2011年10月收治的确诊为ACS拟行经皮冠状动脉介入(PCI)治疗的150例患者随机分为强化治疗组和常规治疗组各75例.强化治疗组术前7d给予阿托伐他汀80mg口服,每天1次;常规治疗组术前7d给予阿托伐他汀20 mg口服,每天1次;余治疗相同.检测治疗前后两组CRP及血脂水平.结果 治疗前、治疗后1d和7d,强化治疗组CRP水平分别为(8.1±3.1)、(12.6±3.2)、(7.9±2.7 )mg/L,常规治疗组分别为(8.21±3.0)、(13.0±3.3)、(11.8±3.1 )mg/L,两组术后CRP水平均先升高后降低,治疗后1d两组无明显差异(P＞0.05),治疗后7d两组比较有显著差异(P＜0.05).两组治疗前TC、TG、HDL、LDL水平无明显差异,两组治疗后TC、TG、LDL均降低,HDL均升高,组内与组间比较均无显著差异(P＞0.05).结论 急性冠状动脉综合征患者行PCI术前应用高剂量的他汀类药物短期强化预处理不仅可以强化调脂作用,而且可以明显减少PCI术的炎症反应,从而减少术后心血管事件的发生.     

多途径抗血小板对急性心肌梗死直接介入治疗的应用探讨

【目的】探讨急性心肌梗死（acutemyocardialinfarction,AMI）患者急诊直接介入治疗（percutaneouscomnaryintervention,PCI）中,多途径抗血小板治疗的安全性、有效性。【方法】124例行急诊直接PCI的AMI患者随机分为多途径抗血小板治疗组（n=66）和双途径抗血小板治疗组（n=58）。多途径抗血小板治疗组接受阿司匹林＋氯吡格雷＋替罗非班方案（氯吡格雷300mg,替罗非班术前、术后使用,术中不用）,双途径抗血小板治疗组接受阿司匹林＋氯吡格雷方案（氯吡格雷600mg）。分析两组的基线资料、胃肠道反应、即刻手术成功率、肌钙蛋白（troponin,TnI）、出血和血小板减少情况,观察住院和随访30d内主要心脏不良事件majoradversecardiacevents,MACE）及30d左室射血分数（1eftventricularejectionfraction,LVEF）。【结果】两组患者均急诊直接PCI手术成功。多途径抗血小板治疗组胃肠道反应、冠脉造影时梗死相关动脉血流情况、24hTnI、30dLVEF显著优于双途径抗血小板治疗组（P〈0．05）。术后血小板计数、住院及随访期间MACE发生、出血情况两组无差异（P〉0．05）。【结论】AMI患者急诊直接PCI多途径抗血小板治疗安全、有效。     

氯吡格雷用药时间对接受急诊介入治疗急性心肌梗死患者临床疗效的影响

Objective To evaluate effect of duration of clopidogrel use on clinical follow-up outcomes in patients with acute myocardial infarction undergoing primary percutaneous coronary intervention. Methods A total of 214 patients with acute myocardial infarction undergoing primary percutaneous coronary intervention between January 2005 to December 2007 were enrolled. All patients were divided into two groups by duration of clopidogrel use; ＜1 year group (n=59) and ≥1 years group (n = 155). Baseline characteristics [age, gender, angiographic characteristics, Killip classification, LVEF (left ventricular ejection fraction) , CK (creatine kinase), CK-MB, CTnI (cardiac troponin-I), hemoglobin levels and history of hypertension, diabetes , hyperlipidemia, obesity and smoking ] of two groups were collected. Clinical follow-up end-point was major adverse cardiac event (MACE) including death, acute myocardial infarction, stent thrombosis and stent restenosis. Clinical follow-up duration was 41.6 ± 16.3 months. MACE occurred in 28 patients. Results Rates of male, infarction site .infarction relative artery, multi-vessel disease, Killip classification (class I) , aspirin use and history of smoking, obesity, hypertension and hyperlipidemia were not different ( P ＞ 0. 05) in duration of clopidogrel use ＜ 1 year group and ≥ 1 years group. Average LVEF, hemoglobin levels and rate of drug-eluting stents were significantly lower in duration of clopidogrel use ＜ 1 year group than that in duration of clopidogrel use ≥1 years group (P ＜0. 0001 ,P ＜0. 0001 ,P=0. 0065). Average CK、CK-MB.CTnI were significantly higher in duration of clopidogrel use ≥ 1 years group than that in duration of clopidogrel use ＜ 1 year group (P ＜ 0. 0001 ). Rate of diabetes and average age were significantly higher in duration of clopidogrel use ＜ 1 year group than that in duration of clopidogrel use ≥1 years group (P =0. 0190, P ＜0. 0001 ). Incidence of MACE in follow-up period was significantly lower in duration of clopidogrel use ≥1 years group than that in duration of clopidogrel use ＜ 1 year group (6.45% vs 30. 51% ,P ＜0. 01). After stopping clopidogrel use, incidence of MACE in follow-up period was significantly lower in duration of clopidogrel use ≥1 years group than that in duration of clopidogrel use ＜ 1 year group (2. 58% vs 20. 34% , P ＜ 0. 01 ) . Conclusion Primary percutaneous coronary intervention is an effective therapeutic method. Incidence of MACE in follow-up period was significantly lower in duration of clopidogrel use ≥1 years group than that in duration of clopidogrel use ＜ 1 year group. Duration of clopidogrel use may influence clinical outcomes in follow-up period in patients with acute myocardial infarction undergoing primary percutaneous coronary intervention.