冠心病患者PCI术后理想双联抗血小板药物治疗

发布时间：2018-11-25 10:14

【摘要】：阿司匹林联合一种P2Y12受体抑制剂的双联抗血小板药物治疗(DAPT)已经成为了急性冠脉综合症(ACS)治疗的基础方案。由于其具有明确的治疗效果,这一药物联合治疗的方法也成为了冠脉支架植入术后的理想选择。对于冠心病行经皮介入治疗(PCI)术后的患者,双联抗血小板药物治疗可以极大地减少术后缺血事件的发生率；但是,也可能增加出血风险。近年来,多个临床研究被设计用来探究能使临床获益最大化的理想双联抗血小板使用方案。而这些研究得出了看似矛盾的结果：一方面,短时间的DAPT可能减少患者出血风险而不显著增加缺血事件的发生率,可能是一种更为安全的方案；另一方面,长时间的DAPT在预防缺血事件上比短时间DAPT可能更具优势,但是增加患者的出血风险。同时,在临床实践中由于存在相当比例的氯吡格雷抵抗患者,针对该部分人群的理想DAPT选择也是临床需要解决的问题。本次研究中,我们对现有的PCI术后双联抗血小板药物治疗的临床研究进行归纳分析；分别对冠心病患者PCI术后双联抗血小板治疗的持续时间和经血小板功能检测指导的双联抗血小板药物治疗进行meta分析,探讨使患者在PCI术后能最大获益的双联抗血小板药物治疗方案。结果显示：冠心病患者PCI术后较长时间的双联抗血小板药物治疗可显著减少主要心血管不良事件(MACE)的发生率,但同时显著增加患者出血事件的发生率。我们发现：与低危的冠心病患者相比,ACS的患者或具有高血栓风险的患者更有可能从长时间的双联抗血小板药物治疗中显著获益。另外,对于行新一代药物涂层支架(DES)植入的患者,较短时间的双联抗血小板治疗的有效性不劣于较长时间双联抗血小板药物治疗,.且减少出血风险。新型P2Y12受体抑制剂的长期使用可能有效减少患者缺血事件的发生率。对于PCI术后经血小板功能试验证实存在治疗后血小板高反应性(HPR)的患者,与常规的双联抗血小板治疗相比,个体化强化的双联抗血小板治疗显著减少血栓事件的发生率而不增加出血事件。提示血小板功能检测可能成为指导患者术后双联抗血小板治疗的理想选择。
[Abstract]:Aspirin combined with a dual antiplatelet inhibitor of P2Y12 receptor therapy for (DAPT) has become the basic regimen for the treatment of acute coronary syndrome (ACS) (ACS). Because of its definite therapeutic effect, this combination therapy is also an ideal choice after coronary stent implantation. For patients with coronary heart disease undergoing percutaneous interventional therapy after (PCI), dual antiplatelet therapy can significantly reduce the incidence of postoperative ischemic events; however, it may also increase the risk of bleeding. In recent years, a number of clinical studies have been designed to explore ideal dual antiplatelet use protocols that maximize clinical benefits. On the one hand, short-term DAPT may reduce the risk of bleeding without significantly increasing the incidence of ischemic events, and may be a safer solution; On the other hand, long-term DAPT may be superior to short-term DAPT in preventing ischemic events, but increases the risk of bleeding in patients. At the same time, due to the presence of a considerable proportion of clopidogrel resistance patients in clinical practice, the ideal selection of DAPT for this part of the population is also a clinical problem to be solved. In this study, we summarized and analyzed the existing clinical studies of dual antiplatelet therapy after PCI. The duration of dual antiplatelet therapy after PCI and the dual antiplatelet therapy guided by platelet function test were analyzed by meta in patients with coronary heart disease. To explore the dual anti-platelet therapy regimen which can benefit the patients most after PCI. The results showed that long-term dual antiplatelet therapy after PCI could significantly reduce the incidence of major adverse cardiovascular events (MACE), but significantly increase the incidence of bleeding events in patients with coronary heart disease (CHD). We found that patients with ACS or with a high risk of thrombus were more likely to benefit significantly from long-term dual antiplatelet therapy than patients with low risk of coronary heart disease. In addition, for patients undergoing new generation drug-coated stent (DES) implantation, the efficacy of short-term dual antiplatelet therapy was no less than that of long-term dual antiplatelet therapy. And reduce the risk of bleeding. Long-term use of new P2Y12 receptor inhibitors may effectively reduce the incidence of ischemic events in patients. In patients with post-treatment platelet hyperreactive (HPR) confirmed by platelet function test after PCI, it was compared with conventional dual antiplatelet therapy. Individual-enhanced dual anti-platelet therapy significantly reduced the incidence of thrombotic events without increasing bleeding events. The results suggest that platelet function test may be an ideal choice for guiding postoperative dual anti-platelet therapy.
【学位授予单位】：浙江大学
【学位级别】：博士
【学位授予年份】：2016
【分类号】：R541.4

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