OPCABG前后凝血功能及阿司匹林抵抗与糖尿病的相关性研究

发布时间：2018-03-22 03:21

  本文选题：冠脉搭桥术　切入点：非体外循环下冠状动脉旁路移植术　出处：《河北医科大学》2017年硕士论文　论文类型：学位论文

【摘要】：目的:本研究旨在应用血栓弹力图(Thrombelastograghy,TEG)测量在非体外循环下冠状动脉旁路移植术(Off-pump coronary artery bypass grafting,OPCABG)围手术期糖尿病患者与非糖尿病患者的凝血功能变化,分析比较两组患者围手术期的TEG各参数值变化,探讨OPCABG对患者凝血功能的影响及糖尿病对OPCABG术后凝血功能的影响;通过对比两组花生四烯酸(Arachidonic acid,AA)抑制率及阿司匹林抵抗(Aspirin resistance,AR)的发生率异同,来评价糖尿病对OPCABG术后AR的影响,将其应用于临床上为冠心病合并糖尿病患者在OPCABG围术期的合理抗血小板治疗提供重要的指导依据。方法:收集2015年12月至2017年1月就诊于我院心外科的冠心病患者,并首次行OPCABG治疗。符合纳入和排除标准,依据WHO的2型糖尿病诊断标准分为糖尿病组(DM组)及非糖尿病组(NDM组)。两组患者入院后术前均口服阿司匹林100mg/d+氯吡格雷75mg/d达五天以上。术后2天开始口服阿司匹林100mg/d+氯吡格雷75mg/d。两组患者均于术前口服阿司匹林100mg/d+氯吡格雷75mg/d达五天后(T0)、术后返回监护室后(T1)、术后口服阿司匹林100mg/d+氯吡格雷75mg/d达5天(T2)采集静脉血,行TEG检测,得出R值,K值,α角,MA值,LY30等指标,观察分析各指标的变化情况。比较DM组及NDM组患者围手术期TEG各项凝血功能参数变化,分析讨论OPCABG对患者凝血功能的影响及糖尿病对OPCABG患者术后凝血功能的影响。两组所有患者均于术前口服阿司匹林100mg/d+氯吡格雷75mg/d达五天后(T0)采集静脉血行TEG血小板检测。选择其中TEG检测阿司匹林反应正常(AA50%)的患者,于术后口服阿司匹林100mg/d+氯吡格雷75mg/d达5天(T2)再次复查TEG血小板检测,比较DM组和NDM组术后AA抑制率及AR的发生率,探讨糖尿病是否与AR相关。1本研究共纳入56例患者,DM组30例,男性,19例;NDM组26例,男性17例。两组OPCABG术后均无死亡病例,无术后早期血栓事件及异常出血等。分析比较两组患者的主要临床资料,均无统计学差异(P0.05)。2组内比较:DM组:与术前T0相比,术后T1及T2时间点R值、K值均减小,α角、MA值增加,差异有统计学意义,且三个时间点两两比较均有统计学差异(P0.05)。NDM组:与术前T0相比,术后T1及T2时间点R值、K值均减小,α角、MA值增加,差异有统计学意义,且三个时间点两两比较均有统计学差异(P0.05)。两组参数变化规律:R值T1时间点下降,T2时间点上升,但仍然小于术前T0时间点;K值术后逐渐减小,MA值、α角术后逐渐增大。DM组LY30各时间点均为0;NDM组LY30各时间点比较差异均无统计学意义(F=0.227,P=0.797)。组间比较:术后返回监护室时(T1时间点):R值在DM组明显低于NDM组,且差别有统计学意义(t=3.611,P=0.001);MA值、K值、α角,差异均无统计学意义(P0.05)。而术前(T0时间点)、术后口服阿司匹林100mg/d+氯吡格雷75mg/d达5天(T2时间点)时DM组与NDM组患者R值、MA值、K值、α角以及LY30,差异均无统计学意义(P0.05)。3从上述病例中选择术前T0时间点TEG血小板检测阿司匹林反应正常(AA50%)的患者,其中NDM组21例,DM组27例。在OPCABG术后口服阿司匹林100mg/d+氯吡格雷75mg/d达5天(T2时间点)DM组AA抑制率显著低于NDM组(t=3.277,P=0.002)。DM组术后口服阿司匹林100mg/d+氯吡格雷75mg/d达5天(T2时间点)AA抑制率明显低于术前T0时间点,差异有统计学意义(t=5.216,P=0.000)。NDM组术后口服阿司匹林100mg/d+氯吡格雷75mg/d达5天(T2时间点)AA抑制率较术前(T0时间点)虽有所减低,但差异无统计学意义(t=1.016,P=0.322)。DM组27例中AR者12例,NDM组21例中AR者3例,提示OPCABG术后早期存在AR,且在DM组AR发生率较NDM组高(χ~2=5.001,P=0.025)。结论:1 OPCABG患者术后早期凝血功能呈现高凝状态。2糖尿病影响OPCABG患者术后当天凝血功能,合并糖尿病的冠心病结果:患者OPCABG术后当天的血液高凝状态程度要高于单纯冠心病患者。但是术后口服阿司匹林及氯吡格雷达5天后两组间凝血功能无明显差异。3合并糖尿病的冠心病患者OPCABG术后血小板聚集抑制率(AA抑制率)明显减低,且较单纯冠心病患者更低、AR发生率更高。4 TEG可及时准确反映体内凝血功能状态,提供较为全面的凝血纤溶功能信息,有助于辅助临床筛查血栓事件高危患者,帮助评价抗血小板治疗的疗效及安全性,对临床个体化治疗有重要的指导意义,并提供合理的诊断依据。
[Abstract]:Objective: This study aims to use the Thrombelastogram (Thrombelastograghy, TEG) measured in off-pump coronary artery bypass grafting (Off-pump coronary artery bypass grafting, OPCABG) in the changes of coagulation function in patients with diabetes mellitus perioperative and non diabetes patients, analysis of perioperative period were compared between the two groups of TEG parameters change, explore effect of OPCABG on coagulation function in patients with diabetes and the influence on blood coagulation function after OPCABG; by comparing the two groups of four arachidonic acid (Arachidonic, acid, AA) and the inhibition rate of aspirin resistance (Aspirin, resistance, AR) the incidence of similarities and differences, to evaluate the influence of diabetes on AR after OPCABG, its application in clinic for patients with coronary heart disease and diabetes in a reasonable perioperative antiplatelet OPCABG treatment provides an important basis for guidance. Methods: from December 2015 to January 2017 in our hospital Heart surgery in patients with coronary heart disease, and treatment of OPCABG. For the first time met the inclusion and exclusion criteria, according to the diagnostic standard of WHO type 2 diabetes were divided into diabetic group (DM group) and non diabetes group (NDM group). Two groups of patients before surgery were given aspirin clopidogrel 100mg/d+ 75mg/ d more than five days after the operation. 2 day oral aspirin clopidogrel 100mg/d+ 75mg/d. two groups of patients in the preoperative aspirin clopidogrel 100mg/d+ 75mg/d up to five days (T0), postoperative ICU after return (T1), postoperative oral aspirin clopidogrel 100mg/d+ 75mg/d for 5 days (T2) collected venous blood detected by TEG. The result showed that R value, K value alpha, angle, MA value, LY30 index, and analyze the changes of each index were observed between DM group and NDM group. The patients with changes of TEG parameters of coagulation operation period, analyze the influence of OPCABG on blood coagulation function in patients suffering from diabetes mellitus and discussion of OPCABG Effect of coagulation function after surgery. All patients in two groups were preoperative aspirin clopidogrel 100mg/d+ 75mg/d up to five days (T0) venous blood collection TEG platelet detection. In TEG detection of aspirin (AA50%) response of normal patients in the postoperative oral aspirin 100mg/d+ and clopidogrel 75mg/d for 5 days (T2) check TEG platelet, DM group and NDM group after AA inhibition rate and the incidence of AR, to investigate whether diabetes is associated with the AR.1 this study included 56 patients, 30 cases of group DM, male, 19 cases; 26 cases in group NDM, 17 cases were male. Two groups after operation were not OPCABG early death, no postoperative thromboembolic events and abnormal bleeding. Analysis of clinical data of the two groups were compared, there was no significant difference (P0.05) of.2 group: DM group: compared with the preoperative T0, T1 and T2 time point R after operation, the K values were decreased, the angle alpha, MA the value increased, the difference was statistically 璁″�︽剰涔�,涓斾笁涓�鏃堕棿鐐逛袱涓ゆ瘮杈冨潎鏈夌粺璁″�﹀樊寮，

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