Department of Geriatric Cardiology, Beijing Anzhen Hospital Affiliated to Capital Medical University, Beijing 100029, China.
Chin Med J (Engl). 2009 Aug 5;122(15):1732-7.
For patients with moderate to high-risk acute coronary syndromes (ACS) who undergo early, invasive treatment strategies, current guidelines recommend the usage of glycoprotein (GP) IIb/IIIa inhibitors as an upstream treatment for a coronary care unit or as an downstream provisional treatment for selected patients who are undergoing percutaneous coronary intervention (PCI). The relative advantage of either strategy is unknown. The purpose of this study was to evaluate the effects of upstream tirofiban versus the effects of downstream tirofiban on myocardial damage and 180-day major adverse cardiovascular events (MACE) after PCI in high-risk non-ST-segment elevation ACS (NSTE-ACS) undergoing PCI.
From July 2006 to July 2007, 160 high-risk NSTE-ACS undergoing PCI were randomized to receive upstream (within 4 - 6 hours before coronary angiography) tirofiban or downstream (the guidewire crossing the lesion) tirofiban, to evaluate the extent of myocardial damage after PCI by quantitatively and qualitatively analyzing the value of cardiac troponin I (cTnI) as well as MB isoenzyme of creatine kinase (CK-MB) before and after PCI. The incidences of 24-hour, 3-day, 7-day, 30-day and 180-day MACE after PCI were followed up and the rates of bleeding complications and thrombocytopenia during tirofiban administration were recorded.
The peak release and cumulative release of cTnI levels within 48 hours after PCI were significantly lower with upstream tirofiban than downstream tirofiban (0.45 vs 0.63 and 0.32 vs 0.43, respectively; P < 0.05). Post-procedural cTnI elevation within 48 hours was significantly less frequent among patients who received the upstream tirofiban than those who received the downstream tirofiban (66.3% vs 87.5%, P < 0.05). The peak and cumulative release of CK-MB levels as well as post-procedural CK-MB elevation within 48 hours after PCI were not significantly different between the two groups (16 vs 14 , 5 vs 3 and 26.3% vs 36.3%, respectively; P > 0.05). The incidences of 24-hour, 3-day, and 7-day MACE after PCI were the same between the two groups (0 vs 0, 0 vs 0 and 1.25% vs 1.25%, respectively). Although the incidences of 30-day and 180-day MACE after PCI were not statistically different between the two groups, the incidences were consistently lower with upstream tirofiban (3.75% vs 6.25% and 12.99% vs 16.67%; P > 0.05). Aging (OR = 1.164, P < 0.001), hypertension (OR = 4.165, P = 0.037) and type 2 diabetes (OR = 13.628, P < 0.001) were independent risk factors of MACE. The timing of administrating the tirofiban (OR = 2.416, P = 0.153) plays an extensive role in the incidence of MACE. The incidences of major and minor bleeding complications as well as mild thrombocytopenia during the administration of tirofiban were similar between the two groups (2.50% vs 1.25%, 1.25% vs 1.25% and 1.25% vs 1.25%, respectively; P > 0.05).
Based on the pretreatment with aspirin and clopidogrel, upstream tirofiban was associated with attenuated minor myocardial damage and the tendency of reducing incidences of 180-day MACE after PCI among high-risk NSTE-ACS patients undergoing PCI. Aging, hypertension and type 2 diabetes were independent risk factors of MACE in high-risk NSTE-ACS patients undergoing PCI associated with tirofiban.
对于接受早期、侵入性治疗策略的中高危急性冠脉综合征（ACS）患者，目前的指南建议使用糖蛋白（GP）IIb/IIIa 抑制剂作为冠状动脉护理单元的上游治疗，或作为接受经皮冠状动脉介入治疗（PCI）的选定患者的下游临时治疗。两种策略的相对优势尚不清楚。本研究的目的是评估高危非 ST 段抬高型 ACS（NSTE-ACS）患者 PCI 前上游比伐卢定与 PCI 后下游比伐卢定对心肌损伤和 180 天主要不良心血管事件（MACE）的影响。
2006 年 7 月至 2007 年 7 月，160 例高危 NSTE-ACS 患者接受 PCI，随机分为接受上游（冠状动脉造影前 4-6 小时）比伐卢定或下游（导丝穿过病变）比伐卢定，通过定量和定性分析肌钙蛋白 I（cTnI）和肌酸激酶同工酶（CK-MB）MB 同工酶在 PCI 前后的价值来评估 PCI 后心肌损伤的程度。对 PCI 后 24 小时、3 天、7 天、30 天和 180 天的 MACE 发生率进行随访，并记录比伐卢定治疗期间出血并发症和血小板减少症的发生率。
与下游比伐卢定相比，上游比伐卢定治疗组患者 PCI 后 48 小时内 cTnI 水平的峰值释放和累积释放显著降低（0.45 对 0.63，0.32 对 0.43；P<0.05）。与下游比伐卢定相比，上游比伐卢定治疗组患者 PCI 后 48 小时内 cTnI 升高的发生率显著降低（66.3%对 87.5%，P<0.05）。两组 PCI 后 48 小时内 CK-MB 水平的峰值和累积释放以及 CK-MB 升高的发生率无显著差异（16 对 14，5 对 3，26.3%对 36.3%；P>0.05）。两组患者 PCI 后 24 小时、3 天和 7 天的 MACE 发生率相同（0 对 0，0 对 0，1.25%对 1.25%）。尽管两组患者 30 天和 180 天的 MACE 发生率无统计学差异，但上游比伐卢定组的发生率始终较低（3.75%对 6.25%，12.99%对 16.67%；P>0.05）。年龄（OR=1.164，P<0.001）、高血压（OR=4.165，P=0.037）和 2 型糖尿病（OR=13.628，P<0.001）是 MACE 的独立危险因素。比伐卢定给药时间（OR=2.416，P=0.153）在 MACE 发生率中起着广泛的作用。两组患者出血并发症和血小板减少症的发生率相似（2.50%对 1.25%，1.25%对 1.25%，1.25%对 1.25%；P>0.05）。
基于阿司匹林和氯吡格雷的预处理，高危 NSTE-ACS 患者 PCI 前使用上游比伐卢定与轻微心肌损伤减轻和 PCI 后 180 天 MACE 发生率降低趋势相关。年龄、高血压和 2 型糖尿病是高危 NSTE-ACS 患者接受比伐卢定治疗相关 MACE 的独立危险因素。
