老年急性心肌梗死患者急诊介入治疗中静脉内应用半剂量替罗非班的临床研究

目的:探讨因急性心肌梗死(AMI)行急诊经皮冠状动脉(冠脉)介入治疗(PCI)的老年患者,冠脉内(IC)联合静脉内应用半剂量替罗非班的有效性及安全性。方法:年龄≥70岁、因AMI行急诊PCI的患者104例,被随机分为常规剂量组(52例)和半剂量组(52列)。两组均IC替罗非班负荷剂量10μg/kg,常规组和半剂量组分别以0.15、0.075μg/(kg·min)持续静脉泵入24 h。比较两组PCI术后心电图ST段完全回落率(STEMI患者),血清高敏肌钙蛋白T(hs-c Tn T)峰值,梗死相关动脉(IRA)血栓积分、TIMI血流分级,TIMI心肌灌注分级(TMPG);二磷酸腺苷(ADP)、花生四烯酸(AA)和胶原(COL)3种诱导剂作用下的血小板聚集程度(全血电阻抗法,WBIA);PCI术后90 d左心室射血分数(LVEF)及主要不良心血管事件(MACEs)发生率的差异。比较两组用药期间出血及血小板减少发生率的差异。结果:半剂量组PCI术后ST段完全回落率(84%vs.86%)、血清hs-c Tn T峰值〔(5.1±1.9)μg/L vs.(5.8±2.6)μg/L〕,PCI术后即刻血栓积分〔(1.0±0.5)分vs.(1.1±0.6)分〕、TIMIⅢ级血流(86%vs.88%)和TMPGⅢ级(78%vs.80%)获得率方面和常规剂量组比较均无统计学差异。半剂量组ADP〔(0.4±0.8)Ohms vs.(0.2±0.7)〕Ohms)、AA〔(0.10±0.36)Ohms vs.(0.06±0.24)Ohms〕、COL〔(11±5)Ohms vs.(9±5)Ohms〕3种诱导剂诱导的血小板聚集程度与常规剂量组比较均无统计学差异。半剂量组患者PCI术后90 d的LVEF(57±6 vs.58±68)、总MACEs的发生率和常规剂量组比较无显著差异。半剂量组总出血事件的发生率显著低于常规剂量组(P<0.05)。两组血小板减少的发生率比较无显著差异。结论:对于行急诊PCI的老年AMI患者,在IC负荷剂量的基础上,静脉内半剂量与常规剂量替罗非班相比较无显著差异,但可以更好地降低出血事件的发生。

Intracoronary bolus plus intravenous half-dose maintenance administration of tirofiban in elderly patients undergoing primary percutaneous coronary intervention for acute myocardial infarction

AIM: To investigate the efficacy and safety of intracoronary( IC) bolus plus intravenous( IV) half-dose maintenance administration of tirofiban in aged patients undergoing primary percutaneous coronary intervention( PCI) for acute myocardial infarction( AMI). METHODS: One hundred and four patients aged 70 years and above undergoing primary PCI for AMI were divided into control group( n = 52)and study group( n = 52). Tirofiban was administered as an intracoronary bolus injection( 10 μg / kg) in all patients followed by maintenance IV infusion at 0. 15 μg /( kg·min) in control group and at 0. 075μg /( kg·min) in study group for 24 h. Complete ST-segment resolution( STR) in STEMI patients,peak concentration of serum high-sensitive cardiac troponin T( hs-c Tn T),scores of thrombus,TIMI flow grade in the infarct-related artery( IRA) and TMI myocardial perfusion grade( TMPG) were analyzed in the two groups. Platelet aggregation in response to adenosine diphosphate( ADP),arachidonic acid( AA) or collagen( COL) was measured with whole blood impedance aggregometry( WBIA) 4 h after tirofiban initiation. Left ventricular ejection fraction( LVEF) and major adverse cardiovascular events( MACEs)were assessed 90 days following PCI. The rates of bleeding and thrombocytopenia were assessed during tirofiban administration. RESULTS: The percentage of patients with complete STR( 84% vs. 86%),peak hs-c Tn T level [( 5. 1 ± 1. 9) μg / L vs.( 5. 8 ± 2. 6) μg / L],scores of thrombus in the IRA( 1. 0 ±0. 5 vs. 1. 1 ± 0. 6),the percentage of patients with TIMI flow score of III( 86% vs. 88%) and TMPG III( 78% vs. 80%) postintervention did not differ significantly between study group and control group.Study group was similar with control group in terms of platelet aggregation in response to ADP ADP[( 0. 4 ± 0. 8) Ohms vs.( 0. 2 ± 0. 7) Ohms],AA [( 0. 10 ± 0. 36) Ohms vs.( 0. 06 ± 0. 24) Ohms],COL[( 11 ± 5) Ohms vs.( 9 ± 5) Ohms]. No significant differences were observed between groups in LVEF( 57 ± 6 vs. 58 ± 68) and composite MACE rate at 90 days after PCI. The total bleeding rate in the study group was lower than in control group( P < 0. 05). Rate of thrombocytopenia was similar between groups. CONCLUSION: Among aged AMI patients undergoing primary PCI,results are similar between half-dose and standard dose maintenance administration of tirofiban in terms of inhibition of platelet aggregation,coronary flow,myocardial perfusion,infarct size,left ventricular systolic function and short-term clinical outcomes,but IC bolus plus intravenous half-dose maintenance administration of tirofiban is superior to standard dose injection in lowering bleeding complications rates.