长期进行双联抗血小板治疗老年患者并发上消化道出血的危险因素分析

目的 探讨双联抗血小板在老年冠心病患者长期治疗中的安全性、并发上消化道出血的发生情况及预防措施.方法 收集长期双联抗血小板治疗并且符合入组标准又最终完成随诊的患者758例,观察终点包括发生消化道出血、死亡、停止应用双联抗血小板药物,最长随诊至入组后6个月.结果 男性426例,女性332例,共有48例患者发生消化道出血,同时应用质子泵抑制剂( PPI)、H2受体阻滞剂(H2RA)、麦滋林+ PPI、麦滋林+H2RA及单纯应用双联抗血小板药物(作为对照组)患者人数分别为108、240、70、102、238例,各组间年龄及阿司匹林、硫酸氢氯吡格雷的用法用量均相同,结果发现5组患者消化道出血的发生人数分别为4、12、1、3、28例.结论 双重抗血小板药物随访6个月内消化道出血的发生率约为6.3％,联合应用麦滋林类胃黏膜保护剂与PPI可最大限度减少消化道出血的发生率.     

高龄急性冠脉综合征患者双联抗血小板治疗的疗效及安全性探讨

目前,双联抗血小板治疗(dual antiplatelet therapy,DAPT)仍然是急性冠脉综合征(ACS)的一线治疗方法。强化抗血小板治疗带来心血管获益的同时,由此引起的出血风险的增加也值得关注。文中通过回顾近些年来国内外几项大型临床试验,综述得出:高龄ACS患者给予DAPT有效且相对安全;对于有出血危险因素及需要长期应用阿司匹林(尤其是接受DAPT)者,可选择较低剂量阿司匹林(75～81 mg.d-1);年龄>75岁者,不推荐给予氯吡格雷负荷剂量(300 mg);服用阿司匹林和(或)氯吡格雷时,不推荐常规应用质子泵抑制剂预防胃肠道不良反应。     

年龄对阿司匹林和氯吡格雷双联抗血小板治疗心脏介入术后临床效果的影响

目的:观察与分析阿司匹林和氯吡格雷双联抗血小板治疗心脏介入术后患者的临床效果.方法:选取我院2015年12月～2016年12月行心脏介入术患者364例,分为高龄组与非高龄组,年龄大于等于70岁为高龄组、小于70岁为非高龄组.结果:两组的支架植入部位、数量、其他合并用药这几项的差异均无统计学意义(P>0.05),阿司匹林长期维持和氯吡格雷维持时间、阿司匹林和氯吡格雷的负荷量组间差异无统计学意义(P>0.05).结论:年龄并不是双联抗血小板治疗决定性的影响因素.阿司匹林和氯吡格雷双联抗血小板治疗心脏介入术的疗效显著且安全性良好.     

冠心病患者抗血小板治疗致上消化道事件分析与对策

目的指导临床权衡对待抗血小板治疗药物与其导致的消化道事件的获益与风险及减少消化道事件的发生。方法分析抗血小板治疗致上消化道事件的机制,针对不同患者的具体情况采取不同的治疗方案。结论实施个体化治疗方案,可减低抗血小板治疗致上消化道事件风险。     

阿司匹林及氯吡格雷双联抗血小板治疗对女性月经的影响

目的观察女性经皮冠状动脉介入治疗(Percutaneous coronary intervention,PCI)术后全程双联抗血小板药物阿司匹林及氯吡格雷口服治疗对月经的影响。方法我院心内科2004年1月至2013年6月诊断为急性冠脉综合征且行冠状动脉支架植入术的住院绝经前女性患者,采用回顾性研究的方法观察其口服双联抗血小板药物治疗前及治疗后6个月、1年的月经情况,并采用PABC评分量表对患者的月经量进行定量评分。结果绝经前女性冠状动脉支架置入术后双联抗血小板药物阿司匹林及氯吡格雷口服治疗1年的月经量较术前无明显变化。结论绝经前女性应用双联抗血小板药物治疗1年,月经量无明显变化,是相对安全的。     

雷贝拉唑和替普瑞酮治疗双联抗血小板所致上消化道出血的对比研究

目的 探讨质子泵抑制剂(PPI)雷贝拉唑和胃黏膜保护剂替普瑞酮对经皮冠状动脉介入(PCI)术后服用双联抗血小板药物患者上消化道出血的预防效果.方法 400例PCI术后服用肠溶阿司匹林合并氯吡格雷纳入本研究,按治疗小组分为4组:常规治疗组100例、PPI组100例、胃黏膜保护剂组100例、PPI+胃黏膜保护剂组100例....     

双联抗血小板应用于穿支动脉脑梗塞静脉溶栓后的效果分析

目的:研究双联抗血小板应用于穿支动脉脑梗塞静脉溶栓后的效果.方法:选取2017年11月～2019年6月某院接收并治疗的50例穿支动脉脑梗塞患者,使用随机数字表法将其分为对照组和双联组各25例.静脉溶栓后对照组单一使用阿司匹林进行治疗,双联组在对照组的基础上使用硫酸氢氯吡格雷进行治疗.治疗两个月后,比较患者的临床疗效、血...     

双联抗血小板药引起经皮冠状动脉介入术围手术期患者急性粒细胞减少一例

白细胞减少是双联抗血小板药物引起的常见不良反应。患者在经皮冠状动脉介入术(percutaneous coronary intervention,PCI)围手术期时出现了急性粒细胞下降,因患者此时既需要进行双联抗血小板治疗,同时又要解决粒细胞缺乏的问题,所以临床药师配合医生查找原因并提出应对方案,     

阿司匹林和氯吡格雷联合抗血小板聚集在冠脉支架术后的临床应用观察

目的 观察非ST段抬高型急性冠脉综合征患者冠脉支架术后规范服用阿司匹林和氯吡格雷的疗效.方法 选取60例非ST段抬高型急性冠脉综合征药物洗脱支架术后患者,分为联合用药组32例,阿司匹林组28例.联合用药组术后规则口服阿司匹林和氯吡格雷,连续11个月;阿司匹林组术后1个月规则口服阿司匹林和氯吡格雷,随后因各种原因自行停服氯吡格雷,仅口服阿司匹林,持续11个月.复查冠脉造影,观察冠脉再狭窄包括需进行再次PCI术或冠状动脉旁路移植的发生率.结果 联合用药组冠脉再狭窄发生率12.5%,阿司匹林组冠脉再狭窄发生率39.3%,2组差异有统计学意义（P〈0.05）.结论 冠脉支架术后患者应规范联合服用阿司匹林和氯吡格雷.     

Risk of major bleeding with concomitant dual antiplatelet therapy after percutaneous coronary intervention in patients receiving long-term warfarin therapy

STUDY OBJECTIVES: To characterize the safety of concomitant aspirin, clopidogrel, and warfarin therapy after percutaneous coronary intervention (PCI), and to identify patient characteristics that increase the risk of hemorrhage. DESIGN: Retrospective, matched cohort study. SETTING: Academic medical center and affiliated outpatient offices. PATIENTS: The active group consisted of 97 patients who underwent PCI from January 1, 2000-September 30, 2005, and received warfarin, aspirin, and clopidogrel; the control group consisted of 97 patients who were individually matched to patients in the active group by procedure type, procedure year, age, and sex. Control patients received aspirin and clopidogrel. MEASUREMENTS AND MAIN RESULTS: Clinical data were collected from inpatient records, outpatient physician office records, and telephone surveys administered to patients or caregivers. The primary end point was major bleeding. The median duration of follow-up after index procedure was 182 days (range 0-191 days) in the active group and 182 days (range 0-213 days) in the control group. Fifty-seven (59%) of the 97 patients in the active group received warfarin for atrial fibrillation. There were 14 major bleeds in the active group (including 1 death) and 3 major bleeds in the control group during the study period. Mean international normalized ratio at the time of bleeding was 3.4. Hazard ratio for major bleeding was 5.0 in patients receiving warfarin therapy (95% confidence interval 1.4-17.8, p=0.012). Aspirin dose, age, sex, body mass index, history of hypertension, diabetes mellitus, intraprocedural glycoprotein IIb-IIIa or anticoagulant type, and postprocedural anticoagulant use did not have a significant effect on the risk of major bleeding. CONCLUSION: Warfarin was an independent predictor of major bleeding after PCI in patients receiving dual antiplatelet therapy. Prospective data to further characterize the safety of concomitant warfarin and dual antiplatelet therapy after PCI are needed.     

PCI患者抗血小板治疗中应关注的几个安全性问题

血小板的异常激活和聚集是急性冠脉综合征（acute coronary syndrome, ACS）病理生理表现中极为重要的一个环节。易损动脉粥样硬化斑块破裂和（或）血管内皮损伤造成内皮下基质成分与循环中血小板接触，直接引起血小板黏附和异常活化，是导致冠状动脉管腔闭塞和发生心肌梗死的关键步骤。     

Platelet reactivity in patients with impaired renal function receiving dual antiplatelet therapy with clopidogrel or ticagrelor

BackgroundSuboptimal platelet inhibition still represents an important challenge, especially for patients undergoing percutaneous coronary interventions (PCI). Chronic kidney disease (CKD) is a common comorbidity of patients with coronary artery disease, and may potentially influence platelet reactivity. So far only few studies have assessed the role of CKD on response to dual antiplatelet therapy (DAPT) with conflicting results. Therefore, the aim of our study was to evaluate the impact of CKD on platelet function in patients treated with DAPT after a recent acute coronary syndrome (ACS) or PCI.MethodsPatients treated with DAPT, acetylsalicylic acid (ASA) + adenosine diphosphate antagonist (ADP-antagonist) such as clopidogrel or ticagrelor, for ACS or elective patients undergoing PCI were scheduled for platelet function assessment at 30–90 days post-discharge. Platelet function was assessed by whole blood impedance aggregometry (Multiplate®- Roche Diagnostics AG), high residual platelet reactivity (HRPR) was considered for ASPI test > 862 AU*min (for ASA) and ADP test values ≥ 417 AU*min (for ADP-antagonists). Chronic renal failure was defined as an estimated glomerular filtration rate of 60 mol/min/1.73m² or less, calculated by applying MDRD (Modification of Diet in renal Disease) formula.ResultsOur population included a total of 537 patients of which 308 (57.3%) received ASA and clopidogrel and 229 (42.6%) received ASA and ticagrelor. Patients with renal failure at baseline (101 out of 537, 18.8%) were older, with higher prevalence of hypertension, previous myocardial infarction and coronary artery bypass graft surgery. Moreover, they had a lower ejection fraction at baseline and were more often in therapy with diuretics, but less often with statins at admission. They had lower haemoglobin and higher glycated haemoglobin. HRPR was observed in 1.5% of patients treated with ASA with no difference according to renal function (p = 0.18). HRPR for ADP-antagonists was observed in 23.7% of patients, with no difference according to renal function (p = 0.50). This result was confirmed either with clopidogrel (31.9% versus 38%, p = 0.41) and ticagrelor (13.1% versus 10.8%, p = 0.99), also after correction for all baseline confounders (clopidogrel: adjusted OR[95%CI] = 1.26 [0.60–2.63], p = 0.54) (ticagrelor: adjusted OR[95%CI] = 0.95 [0.54–1.65], p = 0.84). The absence of association between renal function and platelet reactivity was confirmed at linear regression analysis both with clopidogrel (r = − 0.04, p = 0.52) and ticagrelor (r = 0.006, p = 0.92).ConclusionIn patients receiving DAPT, chronic renal failure did not influence ADP-mediated platelet reactivity, with both ticagrelor or clopidogrel. No influence of chronic renal failure was found on the effectiveness of ASA.     

经皮冠脉介入治疗术后双联抗血小板治疗预后的影响因素分析

目的:进行冠心病患者经皮冠脉介入治疗(percutaneous coronary intervention,PCI)术后服用阿司匹林和氯吡格雷双联抗血小板治疗(dual antiplatelet therapy,DAPT)预后的影响因素分析,以明确术后患者接受DAPT治疗后发生不良事件的可预测因素,为冠心病临床治疗提供依据。方法:回顾性纳入2015年4月至2016年6月于北京大学第一医院行PCI手术的冠心病患者,收集患者的人口学资料、疾病史及实验室检查,并于术后1.5年进行随访,记录患者在此期间患者出血、血管内皮增生、支架内再狭窄(in-stent restosis,ISR)以及再次植入支架的发生情况。采用单因素与多因素Logistic回归分析探讨DAPT治疗预后的独立影响因素,并建立列线图预测模型。结果:纳入的139例患者中,未发生组95人,发生组44人。多因素Logistic回归分析显示年龄、DAPT满1年、D-dimer水平和LDL是双联抗血小板治疗预后的独立影响因素。建立列线图风险预测模型,其ROC曲线下面积(AUC)为0.762。Hosmer-Lemeshow拟合优度检验χ²=8.645,P=0.373,预测模型有较好的校准能力。结论:年龄、DAPT满1年、D-dimer水平和LDL是双联抗血小板治疗预后的独立影响因素,列线图模型预测效能较好。     

Mean platelet volume and high-residual platelet reactivity in patients receiving dual antiplatelet therapy with clopidogrel or ticagrelor

Objective: High on-treatment platelet reactivity (HRPR) is associated with a two- to ninefold increased risk of recurrent ischemic events among patients receiving dual antiplatelet therapy (DAPT) for coronary artery disease. However, its determinants are still poorly understood. The aim of the present study was to assess the impact of mean platelet volume (MPV) on platelet reactivity in patients receiving DAPT after an acute coronary syndrome or PCI.

Methods: Patients treated with DAPT (acetylsalicylic acid [ASA] and clopidogrel or ticagrelor) were scheduled for platelet function assessment at 30 – 90 days post-discharge. By whole blood impedance aggregometry, HRPR was considered for ASPI test > 862 aggregation units (AU)*min (for ASA) and ADP test values ≥ 417 AU*min (for ADP-antagonists).

Results: Our population is represented by a total of 487 patients on DAPT, divided according to MPV tertiles (< 10.4 fl; 10.4 – 11.29 fl; ≥ 11.3 fl). Larger-sized platelets were associated with use of statins (p < 0.001) and beta-blockers (p = 0.03), higher hemoglobin levels (p = 0.002) and lower platelets count (p < 0.001). Higher platelet reactivity was observed at ASPI test in patients with higher MPV (r = 0.12, p = 0.008), but not for ADP-mediated aggregation (r = -0.007, p = 0.88). However, a low prevalence of HRPR was observed with ASA, with no impact of MPV tertiles (1.2 vs 1.1 vs 1.6%, p = 0.70, adjusted OR [95% CI] = 1.05 [0.51 – 1.77], p = 0.87). MPV did not influence the prevalence of HRPR for ADP-antagonists (25.9 vs 1 vs 26.5%, p = 0.89; adjusted OR [95% CI] = 1.1 [0.84 – 1.45], p = 0.50) with similar results among the 259 patients receiving clopidogrel (adjusted OR [95% CI] = 1.15 [0.82 – 1.62], p = 0.43) and the 228 patients on ticagrelor (adjusted OR [95% CI] = 1.46 [0.84 – 2.55], p = 0.18).

Conclusion: In patients receiving DAPT, MPV does not affect the response to major antiplatelet therapies. In fact, MPV elevation does not influence the risk of HRPR with clopidogrel, ticagrelor or ASA.     

泮托拉唑联合吉法酯对经皮冠状动脉介入术后双联抗血小板药物治疗的患者上消化道出血的预防作用研究

目的 探讨泮托拉唑钠肠溶胶囊联合吉法酯片对经皮冠状动脉介入治疗（PCI）术后双联抗血小板药物治疗的患者上消化道出血的预防作用。方法 选取2014年10月-2017年10月在西电集团医院行PCI的患者121例作为研究对象,按照入院先后顺序分为两组。对照组在术后第1天开始口服吉法酯片,100 mg/次,3次/d。观察组在对照组的基础上联合泮托拉唑钠肠溶胶囊,40 mg/d。比较两组患者术后6个月内上消化道出血的发生率、心血管不良事件、消化道不良反应和血小板聚集率。结果 术后6个月观察组患者的上消化道出血发生率显著低于对照组（P<0.05）;心血管不良事件发生率两组比较无统计学差异,观察组消化道不良反应发生率显著低于对照组（P<0.05）。两组患者治疗前后的血小板聚集率相比无统计学差异。结论 泮托拉唑钠肠溶胶囊联合吉法酯片对PCI术后双联抗血小板药物治疗患者上消化道出血具有较好的预防作用,且显著降低消化道不良反应发生率,不增加心血管不良事件发生率,值得临床应用。     

延长双重抗血小板治疗对心肌梗死后高危稳定性冠心病患者预后的影响

目的 探讨延长双重抗血小板治疗对心肌梗死后高危稳定性冠心病患者预后的影响.方法 选取2013年6月至2014年8月本院收治的心肌梗死后高危稳定性冠心病患者84例为研究对象,采用随机数表法分为观察组和对照组,各42例,对照组实施短期(12个月)双重抗血小板治疗,观察组采用长期(24个月)双重抗血小板治疗.比较两组治疗结束时血脂复常率、左室射血分数正常率、血小板聚集率,评价疗效;同时记录两组复合终点事件(心血管死亡、心肌梗死、脑卒中)发生率及消化道出血发生率.结果 观察组血脂复常率为90.5％、左室射血分数正常率为88.1％,显著高于对照组的71.4％、69.0％(P＜0.05),观察组血小板聚集率为4.8％,明显低于对照组的23.8％(P＜0.05);观察组消化道出血率为19.0％,与对照组的14.3％比较,差异无统计学意义(P＞0.05);观察组复合终点事件发生率为21.4％,与对照组的7.1％比较,差异无统计学意义(P＞0.05).结论 在心肌梗死后高危稳定性冠心病患者抗血小板治疗中,长期双重抗血小板治疗可有效改善血脂水平、左室射血分数及血小板聚集率,且长期治疗后消化道出血、复合终点事件发生率与短期双重抗血小板治疗无显著差异,因此延长双重抗血小板治疗的方案值得临床应用.     

急性冠脉综合征PCI术后患者双联抗血小板治疗相关不良反应特点及危险因素分析

目的 探讨急性冠脉综合征（ACS）患者接受经皮冠状动脉介入治疗（PCI）后服用替格瑞洛和阿司匹林双联抗血小板治疗出现不良反应的特点及危险因素。方法 前瞻性纳入2018年3月—2018年6月郑州市第七人民医院收治的PCI术后服用替格瑞洛和阿司匹林的ACS患者100例,采用VerifyNow-P2Y12系统检测患者血小板反应性并随访6个月,根据是否发生相关不良反应分为对照组和不良反应组,收集对比两组患者临床基线资料,采用单因素和多因素Logistic回归分析出血和呼吸困难的危险因素。结果 纳入研究的患者未出现不良反应的40例纳入对照组,出现不良反应的60例纳入不良反应组,双联抗血小板治疗相关不良反应发生率60.0%,84例（84.0%）患者存在低血小板反应性。两组患者在年龄、性别、合并疾病、血小板反应性等方面差异不具有统计学意义（P＞0.05）,不良反应组吸烟患者占比明显高于对照组（51.7%vs27.5%,P=0.016）。不良反应主要临床表现为皮肤黏膜出血和轻中度呼吸困难,用药后1个月内出血和呼吸困难发生率显著高于用药后2～6个月（出血发生率：38.0%vs1.0%,P＜0.001;呼吸困难发生率：32.0%vs8.0%,P＜0.001）。多因素Logisitc回归分析显示老年、女性和贫血是双联抗血小板治疗相关出血的独立危险因素（P＜0.05）,吸烟和出血事件是双联抗血小板治疗相关呼吸困难的独立危险因素（P＜0.05）。结论 ACS患者PCI术后双联抗血小板治疗早期出血和呼吸困难发生率高但程度较轻,对于合并危险因素的患者应提前评估、加强监测,最大限度地降低药品不良反应的发生。     

Effects of pantoprazole on dual antiplatelet therapy in stable angina pectoris patients after percutaneous coronary intervention

BackgroundOur aim was to prospectively assess the potential influence of pantoprazole therapy on the antiplatelet effects of acetylsalicylic acid (ASA) and clopidogrel (CLO) in stable angina pectoris (SAP) patients after percutaneous coronary intervention (PCI).MethodsForty-four patients with SAP (CCS I-III) and successful PCI with stent implantation were enrolled into the study. The patients were divided into group proton pump inhibitors (PPI): 23 patients with indications for PPI (F/M = 9/14; age = 64 ±  9; standard therapy + 20 mg pantoprazole) and the control group (group C): 21 patients (F/M = 6/15; age = 64 ±  8; standard therapy). The platelet function analysis in whole blood based on impedance aggregometry (ASPI, COL, ADP, TRAP tests) using Multiplate – V2.02.11 was performed 18–24 h after the PCI + CLO loading dose (600 mg) and 30 days after PCI.ResultsBoth baseline patient characteristics and clinical outcomes were comparable between the study groups. There were no differences in the mean values of the platelets (PTL) tests measured at the 30^th day after PCI between both groups (PPI vs. C: ASPI: 24.6 ±  10.0 vs. 42.1 ±  14.8U, COL: 32.9 ±  8.6 vs. 34.0 ±  7.7U, ADP: 26.8 ±  12.4 vs. 30.4 ±  8.1U, TRAP: 78.7 ±  16.6 vs. 78.1 ±  22.6U, p = ns). The mean delta values of the PTL tests (18–24 h post-PCI/30 days post-PCI) were also comparable between the groups. The PTL aggregometry results were related to time (ADP, ASPI, TRAP vs. time, p = 0.001; COL vs. time, p = 0.03) – the baseline values of ADP, ASPI, COL and TRAP tests were smaller than those measured after the one-month observation.ConclusionsPantoprazole treatment does not impair the efficacy of dual antiplatelet therapy in patients with SAP after PCI.