血栓弹力图评价患者颅内外动脉狭窄支架置入术后抗血小板聚集药物的疗效

目的采用血栓弹力图（TEG）仪检测颅内外动脉支架置入术（PTAS）后,服用阿司匹林和氯吡格雷患者的血小板抑制情况,以指导PTAS术后抗血小板聚集药物的个体化调整。方法回顾性分析从南京卒中注册系统中纳入的65例脑梗死或者短暂性脑缺血发作患者的临床资料。在PTAS治疗术后第3天抽取静脉血,采用TEG仪检测花生四烯酸（AA）途径诱导的血小板抑制率和腺苷二磷酸（ADP）受体途径诱导的血小板抑制率,比较患者经两种途径诱导的血小板抑制率以及患者对阿司匹林和氯吡格雷治疗反应的差异。结果①阿司匹林对AA途径的抑制率为（80±28）%,显著高于氯吡格雷对ADP受体途径的抑制率（53±31）%,差异有统计学意义,（P〈0.01）。②65例患者中,对阿司匹林组治疗效果良好、有效、反应低、无效者分别为45（69.2%）、8（12.3%）、7（10.8%）、5例（7.7%）,氯吡格雷分别为19（29.2%）、14（21.5%）、23（35.4%）、9例（13.8%）。对阿司匹林反应良好的患者,3例对氯吡格雷无反应,14例反应低下;对氯吡格雷反应良好的患者,均对阿司匹林反应良好或有效。对氯吡格雷反应低下者,4例对阿司匹林反应低,5例对阿司匹林有效,14例效果良好。两种疗效有一定关联性（χ2=33.311,P〈0.01）。③对阿司匹林反应良好＋有效者为53例,反应低＋无效者为12例;而对氯吡格雷反应良好＋有效者为33例;反应低＋无效者为32例,两种药物疗效差异有统计学意义（χ2m=15.042,P〈0.01）。结论采用TEG仪检测PTAS患者的血小板聚集的抑制率,有利于指导临床制定个体化的抗血小板聚集治疗方案。阿司匹林对PTAS患者血小板聚集的抑制作用强于氯吡格雷。患者对阿司匹林和氯吡格雷治疗的反应有差异性,部分对氯吡格雷反应低下者,可能对阿司匹林反应良好或有效。

Evaluation of the efficacy of anti-platelet aggregation drugs in patients using thromboelastograph after percutaneous transluminal angioplasty and stenting

Objective To detect the platelet inhibition of aspirin and clopidogrel in patients after percutaneous transluminal angioplasty and stenting(PTAS) using a thromboelastograph(TEG) instrument in order to guide the individualized adjustment of anti-platelet aggregation drugs after PTAS.Methods The clinical data of 65 patients with ischemic stroke or transient ischemic attack included from Nanjing Stroke Registry Program were analyzed retrospectively.Venous blood samples were collected at day 3 after PTAS.A TEG instrument was used to detect arachidonic acid(AA)-induced inhibition rate of platelet aggregation and adenosine diphosphate(ADP) receptor-induced inhibition rate of platelet aggregation.The AA pathway and ADP receptor-induced inhibition rate of platelet aggregation,as well as the response differences of the patients between aspirin and clopidogrel therapy were compared.Results ①The inhibition rate(80±28%) of aspirin for the AA pathway was significantly higher than that(53±31%) of clopidogrel for the ADP receptor pathway(P<0.01).②Of the 65 patients,the therapeutic effects in 45(69.2%),8(12.3%),7(10.8%) and 5(7.7%) patients were good,effective,low response,and ineffective in the aspirin group,and those in 19(29.2%),14(21.5%),23(35.4%) and 9(13.8%) were good,effective,low response,and ineffective in the clopidogrel group.Of those who had a good response to aspirin,3 had no response to clopidogrel and 14 had low response to clopidogrel;of those who had a good response to clopidogrel,all responded well or effective to aspirin.Of those who had low response to clopidogrel,4 had low response to aspirin,5 had a good response to aspirin,and 14 had good results.The two efficacies had some relevance(χ2=33.311,P<0.01).③A total of 53 patients had a good+effective response to aspirin,and 12 had low response+ineffective to aspirin,while 33 and 32 patients had good+effective and low response+ineffective to clopidogrel.There was significant difference in efficacy between the two drugs(χ2m=15.042,P<0.01).Conclusion Using TEG instrument to detect the inhibition rate of platelet aggregation in patients after PTAS is beneficial to guide the development of therapeutic scheme for individualized anti-platelet aggregation in clinical practice.The inhibitory effect of platelet aggregation of aspirin after PTAS is stronger than that of clopidogrel.The patients show differential responses to aspirin and clopidogrel therapy.Some patients who have low response to clopidogrel may respond well or may be effective to aspirin.