CYP2C19基因指导非体外循环冠脉旁路移植术后抗血小板治疗的意义

目的　探讨根据CYP2C19基因检测结果指导非体外循环冠脉旁路移植术（OPCAB）后患者双联抗血小板治疗可否减少主要心血管不良事件（MACE）发生率及其对出血并发症的影响。方法　选择2018年1月至2020年9月入住河南科技大学第一附属医院拟行OPCAB患者158例为研究对象，按随机数字表法分为基因指导组和传统治疗组，基因指导组根据CYP2C19基因不同分为快代谢型亚组和非快代谢型亚组，快代谢型亚组患者OPCAB术后给予阿司匹林联合氯吡格雷抗血小板治疗，非快代谢型亚组予阿司匹林联合替格瑞洛；传统治疗组随机分为氯吡格雷亚组和替格瑞洛亚组，术后分别予阿司匹林联合氯吡格雷或替格瑞洛治疗。比较患者术后30 d及术后6个月MACE及出血发生率。计量资料采用独立样本t检验，计数资料采用χ²检验。结果　158例患者中，因不符合标准，31例患者先后退出本研究，最终入组127例患者。基因指导组患者63例，其中男42例、女21例，年龄（62.65±7.88）岁，根据CYP2C19基因不同分为快代谢型亚组20例、非快代谢型亚组43例；传统治疗组患者64例，其中男45例、女19例，年龄（61.91±8.99）岁，随机分为氯吡格雷亚组32例、替格瑞洛亚组32例。基因指导组和传统治疗组术后30 d的MACE发生率分别为1.6%（1/63）、10.9%（7/64），组间比较差异有统计学意义（χ²=4.703，P=0.030）；术后6个月MACE发生率分别为3.2%（2/63）、14.1%（9/64），组间比较差异有统计学意义（χ²=5.757，P=0.029）。基因指导组和传统治疗组患者术后30 d出血并发症发生率分别为6.3%（4/63）、10.9%（7/64），组间比较差异无统计学意义（χ²=0.845，P=0.358）；术后6个月出血并发症发生率分别为7.9%（5/63）、12.5%（8/64），组间比较差异无统计学意义（χ²=0.720，P=0.396）。结论　基于CYP2C19基因检测进行精准双联抗血小板治疗可减少OPCAB术后MACE发生率，且不增加出血风险。

Significance of CYP2C19 gene in guiding antiplatelet therapy after OPCAB

Objective　To investigate whether dual antiplatelet therapy guided by CYP2C19 genedetection results can reduce the incidence of major adverse cardiovascularevents (MACE) and its impact on bleeding complications after off-pump coronaryartery bypass grafting (OPCAB). Methods　A total of 158patients scheduled for OPCAB in The First Affiliated Hospital of HenanUniversity of Science and Technology from January 2018 to September 2020 weredivided into a gene guidance group and a traditional treatment group with therandom number table. The gene guidance group was subdivided into a fastmetabolizing subgroup and a non-fast metabolizing subgroup according to CYP2C19gene. The patients in the fast metabolizing subgroup were given aspirincombined with clopidogrel antiplatelet therapy after OPCAB, and the patients inthe non-fast metabolizing subgroup were given aspirin combined with ticagrelor.The traditional treatment group was randomly subdivided into a clopidogrelsubgroup and a ticagrelor subgroup, and the patients were treated with aspirincombined with clopidogrel or ticagrelor respectively. The incidences of MACEand bleeding within 30 days and 6 months after surgery were compared.Independent sample t test was usedfor the measurement data, and χ² test was used for the count data. Results　Among 158 patients, 31 patients withdrew from the study because they didnot meet the criteria, and 127 patients were eventually enrolled. There were 63patients in the gene guidance group, including 42 males and 21 females, aged(62.65±7.88) years, and there were 20 patients in the fast metabolizingsubgroup and 43 patients in the non-fast metabolizing subgroup according toCYP2C19 gene. There were 64 patients in the traditional treatment group,including 45 males and 19 females, aged (61.91±8.99) years, and they wererandomly subdivided into a clopidogrel subgroup (32 cases) and a ticagrelorsubgroup (32 cases). The incidence of MACE within 30 days after surgery was1.6% (1/63) in the gene guidance group and 10.9% (7/64) in the traditionaltreatment group, respectively, with a statistically significant differencebetween the two groups (χ²=4.703, P=0.030); the incidence of MACEwithin 6 months after surgery was 3.2% (2/63) in the gene guidance group and14.1% (9/64) in the traditional treatment group, respectively, with astatistically significant difference between the two groups (χ²=5.757, P=0.029). The incidence of bleedingwithin 30 days after surgery was 6.3% (4/63) in the gene guidance group and10.9% (7/64) in the traditional treatment group, respectively, withoutstatistically significant difference between the two groups (χ²=0.845, P=0.358); the incidence of bleedingwithin 6 months after surgery was 7.9% (5/63) in the gene guidance group and12.5% (8/64) in the traditional treatment group, respectively, withoutstatistically significant difference between the two groups (χ²=0.720, P=0.396). Conclusion　Precise dual antiplatelet therapy based on CYP2C19 gene detection canreduce the incidence of MACE after OPCAB without increasing the risk ofbleeding.