氯吡格雷不同负荷方案对中低危ACS患者支架植入术的影响

目的探讨不同氯吡格雷在冠脉造影术前及术中负荷方式与剂量对中低危急性冠脉综合症(ACS)患者支架植入术后发生不良心血管事件的影响。方法入选279名患者,对照组114名患者,随机分为术前大于6小时氯吡格雷300mg负荷组65人、术中氯吡格雷300mg负荷组60人及术中氯吡格雷600mg负荷组40人。主要观察终点为术后30天内主要不良心血管事件(MACE)。结果各组间MACE事件发生无统计学差异(P=0.45);各组间ADP诱导最大血小板聚集率(ADP-PG)(P=0.05)和血清P-选择素(P=0.06)无统计学差异;术后均未出现大出血,术中600mg组出血发生率有升高趋势(P=0.28);支架平均直径(P=0.03)、术后TIMI血流分级(P=0.02)和术后最大ADP-PG(P=0.01)与MACE事件相关,而负荷方式、负荷剂量以及随访最大ADP-PG等与随访MACE无关。结论氯吡格雷术中负荷方式与术前负荷临床终点相似,600mg负荷剂量未进一步增加患者临床获益,且小出血发生有增加的趋势;如临床需要,在了解了患者冠脉情况后再予氯吡格雷负荷是一个安全且可以考虑的方法。

Effectiveness among different clopidogrel load-dose and load-style in ACS patients undergoing percutaneous stent intervention

Objective This study sought to evaluate effectiveness and safety of different in-laboratory loading-dose in percutaneous coronary intervention(PCI)versus routine before 6-h pre-load.Methods A total of 279 patients(17.6% with non-ST evaluation myocardial infarction) were randomized to receive 300-mg clopidogrel loading dose 6h before PCI(n=65) or a 300-mg(n=65)or 600-mg(n=40)loading dose given in the catheterization lab after coronary angiography and prior the PCI.Primary end point was 30-days incidence of major adverse cardiac event(MACE):cardiovascular death(CV),myocardial infarction(MI),or unplanned target vessel revascularization(TVR).Results There was no significant difference in primary end point among arms(13.2% Vs 7.7% Vs 6.7% Vs7.5%,P =0.45);this was mainly driven by periprocedural MI(P =0.24);concomitantly the Maximum ADP-introduced platelets aggregation(ADP-PG) and P-Selectin were observed resemble within groups.No increased risk of bleeding or vascular complications was observed in groups,the in-lab 600-mg groups performed higher bleeding tendency(15.0%,P =0.28) but without any major bleeding observed in arms.Only the average stent diameter(P =0.03,OR=0.22),in-lab blood flow grade(P =0.02,OR=7.52) and the ADP-PG-max(P =0.01,OR=0.15) correlated to the MACE in follow up.Conclusion The trail indicated that a strategy of in-lab clopidogrel load pre-PCI may have similar clinical outcomes as routine strategy,and in-laboratory high-dose clopidogrel loading did not enhance the clinical benefit.Thus,when indicated,the in-lab clopidogrel administration can be a safe alternation to routine per-load given before knowing the coronary anatomy.