Cardiocenter, Department of Cardiology, 3rd Medical School, Charles University and University Hospital Kralovske Vinohrady, Prague, Czech Republic.
Catheter Cardiovasc Interv. 2010 Feb 1;75(2):158-66. doi: 10.1002/ccd.22248.
Critically-ill patients with ST-segment elevation myocardial infarction (STEMI) often present with insufficient gastroduodenal motility, liver hypoperfusion, and higher levels of circulating catecholamines. All of these factors can lead to reduced efficacy of clopidogrel, which is only available as a p.o. medication. The aim of the study was to compare clopidogrel effectiveness in unstable STEMI patients on mechanical ventilation with stable STEMI patients.
Two groups of twenty patients with STEMI were enrolled. One group (unstable) consisted of 20 hemodynamically unstable patients on mechanical ventilation and catecholamine support. The other group (stable) consisted of 20 control patients (all patients with STEMI in Killip I class). All patients were treated by primary Percutaneous coronary intervention. Blood samples were drawn before (baseline), at 4h (4h+), 24h (1d+) and 2 days (2d+) after clopidogrel administration. Clopidogrel efficacy was assessed by measurement of vasodilator-stimulated phosphoprotein phosphorylation index.
The decrease in the vasodilator-stimulated phosphoprotein (VASP) index was substantially less in unstable patients compared with stable ones (ANOVA, P < 0.001). In stable patients, the VASP index decreased significantly by 20% at 4h+ and by 34% at 1d+, and remained significantly decreased by 31% at 2d+. In unstable patients, the VASP decreased nonsignificantly by 8% at 4h+, and no further decrease of VASP was present (-7% at 1d+, -11% at 2d+).
Laboratory clopidogrel efficacy is lower in patients with MI and severe hemodynamic instability, probably due to splanchnic and liver hypoperfusion and catecholamine use.
患有 ST 段抬高型心肌梗死（STEMI）的危重症患者常伴有胃十二指肠动力不足、肝脏低灌注和循环儿茶酚胺水平升高。所有这些因素都会导致氯吡格雷的疗效降低，而氯吡格雷只能作为口服药物使用。本研究旨在比较机械通气不稳定 STEMI 患者与稳定 STEMI 患者氯吡格雷的疗效。
共纳入 2 组各 20 例 STEMI 患者。不稳定组（n=20）为血流动力学不稳定、需要机械通气和儿茶酚胺支持的患者。稳定组（n=20）为对照组（所有患者均为 Killip I 级 STEMI）。所有患者均接受了经皮冠状动脉介入治疗。在氯吡格雷给药前（基线）、给药后 4 小时（4h+）、24 小时（1d+）和 2 天（2d+）采集血样。通过测量血管扩张刺激磷蛋白磷酸化指数来评估氯吡格雷的疗效。
不稳定组患者的血管扩张刺激磷蛋白（VASP）指数下降明显低于稳定组（方差分析，P<0.001）。在稳定组中，VASP 指数在 4h+时显著下降 20%，在 1d+时下降 34%，在 2d+时仍显著下降 31%。在不稳定组中，VASP 指数在 4h+时仅下降 8%，且无进一步下降（1d+时下降 7%，2d+时下降 11%）。
对于伴有严重血流动力学不稳定的 MI 患者，实验室氯吡格雷疗效较低，可能与内脏和肝脏低灌注以及儿茶酚胺的使用有关。
