替格瑞洛序贯氯吡格雷在老年糖尿病合并急性冠脉综合征患者中的应用
|
摘要
目的:探讨老年糖尿病合并急性冠脉综合征患者合理的双联抗血小板治疗方案。方法:入选河南省胸科医院2015-12-2016-12住院行经皮冠状动脉介入治疗(PCI)的老年糖尿病合并急性冠脉综合征患者共196例,按1∶1比例随机分为2组。对照组:PCI术后口服阿司匹林肠溶片100mg/d+替格瑞洛片90mg/次、2次/d,连续治疗1年;治疗组:PCI术后口服阿司匹林肠溶片100mg/d+替格瑞洛片90mg/次、2次/d,连续治疗6个月,然后改为口服阿司匹林肠溶片100mg/d+硫酸氢氯吡格雷片75mg/d,连续治疗6个月。记录PCI术后9、12个月时主要及次要心血管终点事件及出血(颅内出血、消化道出血、眼底出血、皮肤黏膜出血)不良反应发生率。结果:治疗9个月及12个月时,对照组(87例)和治疗组(86例)主要心血管不良事件发生率无显著性差异(9个月:4.60%∶5.82%;12个月:6.90%∶8.15%,P>0.05),次要心血管不良事件发生率无显著性差异(9个月:5.75%∶4.65%;12个月:6.90%∶8.15%,P>0.05)。治疗9个月时,两组出血发生率无显著性差异(13.80%∶5.81%,P>0.05);治疗12个月时,对照组的总体出血发生率显著高于治疗组,差异有统计学意义(22.99%∶6.98%,P<0.05),其中颅内、消化道和皮肤黏膜出血的发生率无显著性差异(颅内:1.15%∶0.00%;消化道:6.90%∶2.33%;皮肤黏膜:2.30%∶1.16%,P>0.05),眼底出血的发生率对照组显著高于治疗组,差异有统计学意义(12.64%∶3.49%,P<0.05)。结论:老年糖尿病合并急性冠脉综合征患者行PCI术后,采用替格瑞洛序贯口服氯吡格雷可减少出血并发症,提高患者生活质量,改善心血管预后。
Objective:To explore a rational sequential dual antiplatelet therapy in elderly diabetic patients with acute coronary syndrome.Method:A total of 196 consecutive elderly diabetic patients with acute coronary syndrome who underwent percutaneous coronary intervention(PCI)in Henan Province Chest Hospital from December 2015 to December 2016 were enrolled.Patients were randomly divided into treatment group and control group(1∶1ratio).Patients in control group received aspirin 100 mg once daily and ticagrelor 90 mg twice daily after PCI for 1year,while patients in treatment group received aspirin 100 mg once daily and ticagrelor 90 mg twice daily for 6 months,following aspirin 100 mg once daily and clopidogrel 75 mg once daily for next 6 months.The primary and secondary outcomes and the incidence of adverse reactions(intracranial hemorrhage,gastrointestinal bleeding,fundus hemorrhage,skin mucosal hemorrhage)within 9 months and 12 months after PCI were recorded.Result:After9and 12 months,there was no significant difference in the incidence of primary(after 9 months:4.60% vs5.82%;after 9 months:6.90% vs 8.15%,P>0.05)and secondary(after 9 months:5.75% vs 4.65%;after 9 months:6.90% vs 8.15%,P>0.05)adverse cardiovascular events between two groups.There was no significant difference in the incidence of bleeding within 9 months between two groups(13.80% vs 5.81%,P>0.05).However,the incidence of bleeding within 12 months in control group was significantly higher than that in treatment group(22.99% vs 6.98%,P<0.05).Although the incidence of intracranial hemorrhage(1.15% vs 0.00%),gastrointestinal tract(6.90% vs 2.33%)or skin mucosal hemorrhage(2.30% vs 1.16%)between two groups had no difference(all P>0.05),the incidence of fundus hemorrhage was significantly higher in control group than that in treatment group(12.64% vs 3.49%,P<0.05).Conclusion:For elderly diabetic patients with acute coronary syndrome,ticagrelor-sequenced-clopidogrel after PCI could reduce bleeding complications,increase patients' quality of life and finally improve the prognosis.
Objective:To explore a rational sequential dual antiplatelet therapy in elderly diabetic patients with acute coronary syndrome.Method:A total of 196 consecutive elderly diabetic patients with acute coronary syndrome who underwent percutaneous coronary intervention(PCI)in Henan Province Chest Hospital from December 2015 to December 2016 were enrolled.Patients were randomly divided into treatment group and control group(1∶1ratio).Patients in control group received aspirin 100 mg once daily and ticagrelor 90 mg twice daily after PCI for 1year,while patients in treatment group received aspirin 100 mg once daily and ticagrelor 90 mg twice daily for 6 months,following aspirin 100 mg once daily and clopidogrel 75 mg once daily for next 6 months.The primary and secondary outcomes and the incidence of adverse reactions(intracranial hemorrhage,gastrointestinal bleeding,fundus hemorrhage,skin mucosal hemorrhage)within 9 months and 12 months after PCI were recorded.Result:After9and 12 months,there was no significant difference in the incidence of primary(after 9 months:4.60% vs5.82%;after 9 months:6.90% vs 8.15%,P>0.05)and secondary(after 9 months:5.75% vs 4.65%;after 9 months:6.90% vs 8.15%,P>0.05)adverse cardiovascular events between two groups.There was no significant difference in the incidence of bleeding within 9 months between two groups(13.80% vs 5.81%,P>0.05).However,the incidence of bleeding within 12 months in control group was significantly higher than that in treatment group(22.99% vs 6.98%,P<0.05).Although the incidence of intracranial hemorrhage(1.15% vs 0.00%),gastrointestinal tract(6.90% vs 2.33%)or skin mucosal hemorrhage(2.30% vs 1.16%)between two groups had no difference(all P>0.05),the incidence of fundus hemorrhage was significantly higher in control group than that in treatment group(12.64% vs 3.49%,P<0.05).Conclusion:For elderly diabetic patients with acute coronary syndrome,ticagrelor-sequenced-clopidogrel after PCI could reduce bleeding complications,increase patients' quality of life and finally improve the prognosis.
引文
[1]Valgimigli M,Bueno H,Byrne RA,et al.2017ESC focused update on dual antiplatelet therapy in coronary artery disease developed in collaboration with EACTS:The Task Force for dual antiplatelet therapy in coronary artery disease of the European Society of Cardiology(ESC)and of the European Association for Cardio-Thoracic Surgery(EACTS)[J].Eur Heart J,2018,39(3):213-260.
[2]国家卫生计生委合理用药专家委员会,中国药师协会.冠心病合理用药指南[J].中国医学前沿杂志(电子版),2016,8(6):19-108.
[3]Andreotti F,Rocca B,Husted S,et al.Antithrombotic therapy in the elderly:expert position paper of the European Society of Cardiology Working Group on Thrombosis[J].Eur Heart J,2015,36(46):3238-3249.
[4]Fox KA,Carruthers K,Steg PG,et al.Has the frequency of bleeding changed over time for patients presenting with an acute coronary syndrome?The global registry of acute coronary events[J].Eur Heart J,2010,31(6):667-675.
[5]中国医师协会急诊医师分会,中华医学会心血管病学分会,中华医学会检验医学分会.急性冠脉综合征急诊快速诊疗指南[J].中华急诊医学杂志,2016,25(4):397-404.
[6]American Diabetes Association.Standards of medical care in diabetes 2016[J].Diabetes Care,2016,39(Suppl 1):S4-5.
[7]Ahmed N,Kazmi S,Nawaz H,et al.Frequency of diabetes mellitusin patients with acute coronary syndrome[J].J Ayub Med Coll Abbottabad,2014,26(1):57-60.
[8]王志军,张鹏宇,周建芝,等.冠心病合并糖尿病患者联合抗血小板药物抵抗的相关研究[J].临床心血管病杂志,2016,32(10):978-982.
[9]胡华兵,胡正清,徐广,等.血清C-反应蛋白及同型半胱氨酸水平与冠心病PCI预后的相关性研究[J].临床心血管病杂志,2016,32(9):914-917.
[10]肖童,胡天勇,刘媛.超敏C-反应蛋白在老年糖尿病合并心绞痛患者中的临床价值[J].中国实用医刊,2017,44(11):99-101.
[11]Rossington JA,Brown OI,Hoye A.Systematic review and meta-analysis of optimal P2Y12blockade in dual antiplatelet therapy for patients with diabetes with acute coronarysyndrome[J].Open Heart,2016,3(1):e000296.
[12]Zhang H,Hu X,Wu Q,et al.Impact of diabetes on bleeding events in ST-elevation myocardial infarction patients after urgent percutaneous coronary intervention:a retrospective cohort study[J].Medicine(Baltimore),2016,95(33):e4470.
[13]James S,Angiolillo DJ,Cornel JH,et al.Ticagrelor vs.clopidogrel in patients with acute coronary syndromes and diabetes:a substudy from the PLATelet inhibition and patient Outcomes(PLATO)trial[J].Eur Heart J,2010,31(24):3006-3016.
[14]Park KH,Jeong MH,Ahn Y,et al.Comparison of short-term clinical outcomes between ticagrelor versus clopidogrel in patients with acute myocardial infarction undergoing successful revascularization;from Korea Acute Myocardial Infarction Registry-National Institute of Health[J].Int J Cardiol,2016,215:193-200.
[15]Hassan AK,Bergheanu SC,Stijnen T,et a1.Late stent malapposition risk is higher after drug-eluting stent compared with bare-metal stent implantation and associates with late stent thrombosis[J].Eur Heart J,2010,31(10):1172-1180.
[16]延荣强,原鹏,王晏平,等.ADP-P2Y12受体拮抗剂序贯疗法优化ACS患者抗血小板策略的临床研究[J].中国心血管病研究,2015,13(8):706-709.
[17]中华医学会眼科学会眼底病学组.我国糖尿病视网膜病变临床诊疗指南(2014年)[J].中华眼科杂志,2014,50(11):851-865.
[2]国家卫生计生委合理用药专家委员会,中国药师协会.冠心病合理用药指南[J].中国医学前沿杂志(电子版),2016,8(6):19-108.
[3]Andreotti F,Rocca B,Husted S,et al.Antithrombotic therapy in the elderly:expert position paper of the European Society of Cardiology Working Group on Thrombosis[J].Eur Heart J,2015,36(46):3238-3249.
[4]Fox KA,Carruthers K,Steg PG,et al.Has the frequency of bleeding changed over time for patients presenting with an acute coronary syndrome?The global registry of acute coronary events[J].Eur Heart J,2010,31(6):667-675.
[5]中国医师协会急诊医师分会,中华医学会心血管病学分会,中华医学会检验医学分会.急性冠脉综合征急诊快速诊疗指南[J].中华急诊医学杂志,2016,25(4):397-404.
[6]American Diabetes Association.Standards of medical care in diabetes 2016[J].Diabetes Care,2016,39(Suppl 1):S4-5.
[7]Ahmed N,Kazmi S,Nawaz H,et al.Frequency of diabetes mellitusin patients with acute coronary syndrome[J].J Ayub Med Coll Abbottabad,2014,26(1):57-60.
[8]王志军,张鹏宇,周建芝,等.冠心病合并糖尿病患者联合抗血小板药物抵抗的相关研究[J].临床心血管病杂志,2016,32(10):978-982.
[9]胡华兵,胡正清,徐广,等.血清C-反应蛋白及同型半胱氨酸水平与冠心病PCI预后的相关性研究[J].临床心血管病杂志,2016,32(9):914-917.
[10]肖童,胡天勇,刘媛.超敏C-反应蛋白在老年糖尿病合并心绞痛患者中的临床价值[J].中国实用医刊,2017,44(11):99-101.
[11]Rossington JA,Brown OI,Hoye A.Systematic review and meta-analysis of optimal P2Y12blockade in dual antiplatelet therapy for patients with diabetes with acute coronarysyndrome[J].Open Heart,2016,3(1):e000296.
[12]Zhang H,Hu X,Wu Q,et al.Impact of diabetes on bleeding events in ST-elevation myocardial infarction patients after urgent percutaneous coronary intervention:a retrospective cohort study[J].Medicine(Baltimore),2016,95(33):e4470.
[13]James S,Angiolillo DJ,Cornel JH,et al.Ticagrelor vs.clopidogrel in patients with acute coronary syndromes and diabetes:a substudy from the PLATelet inhibition and patient Outcomes(PLATO)trial[J].Eur Heart J,2010,31(24):3006-3016.
[14]Park KH,Jeong MH,Ahn Y,et al.Comparison of short-term clinical outcomes between ticagrelor versus clopidogrel in patients with acute myocardial infarction undergoing successful revascularization;from Korea Acute Myocardial Infarction Registry-National Institute of Health[J].Int J Cardiol,2016,215:193-200.
[15]Hassan AK,Bergheanu SC,Stijnen T,et a1.Late stent malapposition risk is higher after drug-eluting stent compared with bare-metal stent implantation and associates with late stent thrombosis[J].Eur Heart J,2010,31(10):1172-1180.
[16]延荣强,原鹏,王晏平,等.ADP-P2Y12受体拮抗剂序贯疗法优化ACS患者抗血小板策略的临床研究[J].中国心血管病研究,2015,13(8):706-709.
[17]中华医学会眼科学会眼底病学组.我国糖尿病视网膜病变临床诊疗指南(2014年)[J].中华眼科杂志,2014,50(11):851-865.