高危急性冠状动脉综合征介入治疗早期或即刻应用替罗非班对主要不良心血管事件的影响

目的 观察高危非ST段抬高急性冠状动脉综合征(NSTE-ACS)经皮冠状动脉介入治疗(PCI)术前早期应用和术前即刻应用替罗非班对血小板功能和180 d主要不良心血管事件(MACE)的影响,探讨替罗非班的最佳应用时机.方法 2006年7月至2007年7月,160例备行PCI的高危NSTE-ACS患者随机分配到PCI前早期应用组(冠状动脉造影前4～6 h应用替罗非班)和PCI前即刻应用组(导丝通过冠状动脉病变后应用替罗非班).观察两组入院后、冠状动脉造影前和PCI后的血小板聚集率,随访术后24 h、3 d、7 d、30 d和180 d MACE.记录使用替罗非班治疗期间的出血并发症和血小板减少症的发生率.结果 应用替罗非班后,两组血小板聚集率均显著降低(P＜0.05).PCI前早期应用组冠状动脉造影前的血小板聚集率显著低于PCI前即刻应用组(8%比42%,P＜0.05).两组PCI后24 h和3 d内均未发生MACE,7 d MACE发生率均为1.3%.PCI前早期应用组术后30 d(3.8%比6.3%,P＞0.05)和180 d(13.0%比16.7%,P＞0.05)MACE发生率均低于PCI术前即刻应用组.两组180 d无MACE发生的生存率分别为87.0%和83.7%(P＞0.05).增龄(OR=1.164,P＜0.001)、高血压(OR=4.165,P=0.037)和2型糖尿病(OR=13.628,P＜0.001)是发生MACE的独立危险因素.替罗非班的应用时机对MACE发生率有一定程度的影响(OR=2.416,P=0.153).在使用替罗非班治疗期间,两组重度出血并发症发生率(2.5%比1.3%.P＞0.05)差异无统计学意义,中度出血并发症和轻度血小板减少症发生率均为1.25%.结论 在阿司匹林和氯吡格雷抗血小板治疗的基础上,高危NSTE-ACS患者PCI前早期应用替罗非班比PCI前即刻应用,能及早强化抗血小板治疗,有减少PCI后MACE发生率的趋势.增龄、高血压和2型糖尿病是高危NSTE-ACS患者PCI联合替罗非班治疗中发生MACE的独立危险因素.

Effects of upstream tirofiban versus downstream tirofiban on platelet aggregation and clinical outcomes in patients with high-risk acute coronary syndromes undergoing percutaneous coronary interventions

Objective To observe the effects of upstream versus downstream application of tirofiban on platelet aggregation and clinical outcomes(major adverse cardiovascular event,MACE)in patients with high-risk nor-ST-segment elevation acute coronary syndromes(NSIE-ACS)undergoing percutaneous coronary intervention(PCI).Methods From July 2006 to July 2007,160 higll-risk NSTE-ACS patients undergoing PCI were randomized to receive upstream(4-6 h prior PCI)tirofiban and downstream (immediately prior to PCI)tirofibarL Platelet aggregation inhibition was determined at admission,before coronary angiography and dter PCL Incideaces of MACE at 1,3,7,30 and 180 days after PCI were compared.The incidences of bleeding complications and thrombocytopenia during firofiban treatments wete recorded.Results The extent of platelet aggregation inhibition post tirofiban was significantly greater in upstream tirofiban than that in downstream tirofiban group(8%vs.42%,P＜0.05).The incidences of MACE at various time points were similar between the two groups(all P＞0.05).Aging,hypertension and type-2 diabetes were independent risk factors of MACE.The incidences of major and minor bleeding complications as well as mild thrombocytopenia during tirofiban treatments were similar between the two groups(2.5%vs.1.3%,1.3%vs.1.3%and 1.3%vs.1.3%,respectively;all P＞0.05).Conclusion On top of aspirin and clopidogrel,upstream application of tirofiban is associated with increased platelet aggregation inhibition but the incidences of MACE up to 180 days post tirofiban are similar in the upstream and downstream tirofiban treated patients with high-risk NSTE-ACS after PCI.Asins,hypertension and type-2 diabetes were independent risk factors of MACE in these patients.