Bertrand Olivier F, Larose Eric, Rodés-Cabau Josep, Gleeton Onil, Taillon Isabelle, Roy Louis, Poirier Paul, Costerousse Olivier, Larochellière Robert De
Hôpital Laval, Institut Universitaire de Cardiologie et de Pneumologie, Québec City, Québec, Canada.
Am Heart J. 2009 Jan;157(1):164-9. doi: 10.1016/j.ahj.2008.09.010. Epub 2008 Nov 6.
Bleeding has recently emerged as predictor of early and late mortality after percutaneous coronary intervention (PCI) using femoral approach. Transradial PCI is associated with a lower risk of access-site complications than femoral approach. We evaluated the predictors of bleeding and the impact of major bleeding on death and major adverse cardiac events (MACE) after transradial PCI and maximal antiplatelet therapy.
In the EASY (EArly discharge after transradial Stenting of coronarY arteries) trial, 1,348 patients with acute coronary syndrome were enrolled and underwent transradial PCI. All patients received clopidogrel (90% > or =12 hours pre-PCI) and a bolus of abciximab before first balloon inflation. Univariate and multivariate analyses to identify predictors and prognostic impact of major bleeding on death and MACE (death, myocardial infarction, and target vessel revascularization) were performed.
From the study population, 19 (1.4%) patients presented major bleeding. Patients with bleeding were older, had lower creatinine clearance, more often had 3-vessel disease and > or =3 dilated sites, and had longer procedures. Independent predictors of bleeding were creatinine clearance <60 mL/min (odds ratio [OR] 3.26, 95% confidence interval [CI] 1.10-8.67, P = .022), procedure duration (OR 2.95, 95% CI 1.12-8.31, P = .032), and sheath size (OR 5.34, 95% CI 1.44-34.65, P = .029). In patients with major bleeding, the incidence of MACE was higher at 30 days (37% vs 3%), 6 months (42% vs 8%), and 12 months (53% vs 12%; P < .0001 for all comparisons). By multivariate analysis, major bleeding was an independent predictive factor of 1-year mortality and MACE.
After transradial PCI and maximal antiplatelet therapy, the incidence of major bleeding remains low. Major bleeding is an independent predictive factor of adverse acute and 1-year outcomes, regardless of the access site.
出血最近已成为经股动脉途径进行经皮冠状动脉介入治疗（PCI）后早期和晚期死亡率的预测指标。与股动脉途径相比，经桡动脉PCI发生穿刺部位并发症的风险较低。我们评估了经桡动脉PCI及最大程度抗血小板治疗后出血的预测因素以及严重出血对死亡和主要不良心脏事件（MACE）的影响。
在“冠状动脉经桡动脉支架置入术后早期出院（EASY）”试验中，纳入1348例急性冠状动脉综合征患者并进行经桡动脉PCI。所有患者均接受氯吡格雷（90%在PCI前≥12小时用药），并在首次球囊扩张前给予一剂阿昔单抗。进行单因素和多因素分析以确定严重出血对死亡和MACE（死亡、心肌梗死和靶血管血运重建）的预测因素及预后影响。
在研究人群中，19例（1.4%）患者发生严重出血。出血患者年龄较大，肌酐清除率较低，更常患有三支血管病变且扩张部位≥3处，手术时间更长。出血的独立预测因素为肌酐清除率<60 mL/分钟（比值比[OR] 3.26，95%置信区间[CI] 1.10 - 8.67，P = 0.022）、手术持续时间（OR 2.95，95% CI 1.12 - 8.31，P = 0.032）和鞘管尺寸（OR 5.34，95% CI 1.44 - 34.65，P = 0.029）。在发生严重出血的患者中，30天时MACE的发生率较高（37%对3%），6个月时（42%对8%），12个月时（53%对12%；所有比较P < 0.0001）。通过多因素分析，严重出血是1年死亡率和MACE的独立预测因素。
经桡动脉PCI及最大程度抗血小板治疗后，严重出血的发生率仍然较低。严重出血是不良急性和1年结局的独立预测因素，与穿刺部位无关。
