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血栓弹力图检测在急性冠脉综合征患者中的临床价值
Clinical usefulness of Thrombelastograph in patients with acute coronary syndrome

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DOI:
作者:
吴鸿谊 钱菊英 王齐兵 孙爱军 葛均波
WU Hong-yi, QIAN Jü-ying, Wang Qi-bing, Sun Ai-jun, GE Jun-bo.
作者单位:
复旦大学附属中山医院心内科
Department of Cardiology, Zhongshan Hospital, Fudan University
关键词:
急性冠脉综合征; 血小板; 氯吡格雷; 经皮冠状动脉介入治疗
Acute coronary syndrome; Platelet; Clopidogrel; Percutaneous coronary intervention
摘要:
目的：在药物支架术后的急性冠脉综合征（ACS）患者中，评价血栓弹力图（TEG）检测的抗血小板药物反应性与近期临床预后的关系。 方法：447例急性冠脉综合征患者进行了前瞻性观察，患者均接受冠脉造影并植入药物支架，在双联抗血小板药物负荷24小时后，通过TEG检测患者的血小板功能。若ADP诱导的血小板抑制率＜30%，则认为氯吡格雷反应低下；若AA诱导的血小板抑制率＜50%，则认为阿司匹林反应低下。临床随访1个月有无缺血性事件的发生，缺血性事件包括：心源性死亡、非致死性心肌梗死和缺血性脑卒中。 结果：氯吡格雷反应性存在明显的差异，呈正态分布，其中82例（18.3%）患者存在氯吡格雷反应低下；而阿司匹林反应呈反应良好群集现象。447例患者中，有13例（2.9%）1个月内发生了缺血性事件；事件组ADP诱导的血小板抑制率明显低于无事件组（35.7±23.3% 比 54.7±24.6%，p=0.006）；事件组中残留高血小板活性（MAADP＞47mm）的比例明显高于无事件组（61.5% 比 21.9%，p=0.001）。氯吡格雷反应低下(ORadj=5.031，95%CI: 1.566-16.155，p=0.007)和糖尿病(ORadj=3.930, 95%CI: 1.206-12.802, p=0.023)是预测近期缺血性事件的独立危险因素。 结论： 通过TEG检测ACS患者血小板功能有助于发现患者对氯吡格雷反应的差异，氯吡格雷反应低下的患者近期发生缺血性事件的风险明显增加。
Objective: To evaluate the prognostic value of platelet function assessed by Thrombelastograph(TEG) in patients with acute coronary syndrome(ACS) receiving drug-eluting stents(DES). Methods: We consecutively enrolled 447 Chinese patients with ACS receiving DES and dual anti-platelet treatment. Blood for TEG analysis was sampled, 24 hours after clopidogrel and aspirin loading. Clopidogrel low-responsiveness was defined as ＜30% ADP-induced inhibition. Aspirin low-responsiveness was defined as less than 50% platelet inhibition after stimulation by AA. Ischemic event was the composite of cardiovascular death, nonfatal myocardial infarction, or stroke. Results: Heterogeneous anti-platelet effects of clopidogrel were observed in the overall patient population as depicted by the normal bell-shaped distribution of platelet aggregation. Of the 447 patients, 18.3% (82) were categorized as clopidogrel low-responsiveness. However, only 43 (9.6%) patients were categorized as aspirin low-responsiveness. Ischemic events occurred within 1 month in 13 (2.9%) patients; on-clopidogrel platelet inhibition was significantly lower in patients with events than in those without events (35.7±23.3% vs. 54.7±24.6%，p=0.006). High residual platelet reactivity (MAADP＞47mm) was more frequently observed in patients with events (61.5% vs. 21.9%, p=0.001). Multivariable logistic regression analyses showed a significant correlation of clopidogrel low-responsiveness (ORadj=5.031，95%CI: 1.566-16.155，p=0.007), as well as diabetes mellitus with one-month clinical outcome (ORadj=3.930, 95%CI: 1.206-12.802, p=0.023). Conclusion: TEG might be a valuable tool to assess a response to antiplatelet therapy. Low response to clopidogrel indentified by TEG was associated with a worse short-term clinical outcome.

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