非 ST 段抬高型急性冠状动脉综合征患者中氯吡格雷和糖蛋白 IIb/IIIa 抑制剂的未充分利用：加拿大急性冠状动脉事件全球登记处（GRACE）的经验。

Underutilization of clopidogrel and glycoprotein IIb/IIIa inhibitors in non-ST-elevation acute coronary syndrome patients: the Canadian global registry of acute coronary events (GRACE) experience.

机构信息

Terrence Donnelly Heart Centre, Division of Cardiology, St. Michael's Hospital, University of Toronto, and the Canadian Heart Research Centre, Toronto, Ontario, Canada.

出版信息

Am Heart J. 2009 Dec;158(6):917-24. doi: 10.1016/j.ahj.2009.09.016.

DOI:10.1016/j.ahj.2009.09.016

PMID:19958857

Abstract

BACKGROUND

There are limited contemporary data on the early use of clopidogrel or glycoprotein (Gp) IIb/IIIa inhibitors, alone versus combination therapies, in non-ST-elevation acute coronary syndrome (NSTE-ACS).

METHODS

This study included 5,806 Canadian NSTE-ACS patients with elevated cardiac biomarker and/or ST deviation on presentation in the prospective GRACE between 2003-2007. We stratified the study population according to the management strategy (non-invasive vs invasive) and into low-(GRACE risk score <or=108), intermediate- (109-140), and high-risk groups (>or=141).

RESULTS

Overall, 3,893 patients (67.1%) received early (<or=24 hours of admission) antiplatelet therapy; the rates of use were 76%, 73%, and 57% in the low-, intermediate-, and high-risk groups, respectively (P for trend < .001). Only 54% of the conservatively managed patients and 12% of the invasively managed patients received early clopidogrel and GpIIb/IIIa inhibitors, respectively. High-risk patients were less likely (adjusted odds ratio = 0.48, 95% CI 0.39-0.59, P < .001) to receive early clopidogrel or GpIIb/IIIa inhibitors, whereas in-hospital catheterization was an independent positive predictor (adjusted odds ratio = 2.02, 95% CI 1.74-2.34, P < .001) of use.

CONCLUSIONS

In this contemporary NSTE-ACS population, both clopidogrel and GpIIb/IIIa inhibitors were targeted toward patients treated with an invasive strategy but paradoxically toward the lower-risk group. In particular, clopidogrel appeared to be underused among conservatively managed patients despite its proven efficacy, whereas GpIIb/IIIa inhibitors were administered to only a minority of the high-risk patients with elevated cardiac biomarkers. Our findings emphasize the ongoing need to promote the optimal use of evidence-based antiplatelet therapies among high-risk patients with NSTE-ACS.

摘要

背景

目前关于非 ST 段抬高型急性冠状动脉综合征（NSTE-ACS）患者早期使用氯吡格雷或糖蛋白（GP）IIb/IIIa 抑制剂的当代数据有限，单独使用或联合使用这两种药物的疗效也存在差异。

方法

这项研究纳入了 5806 例于 2003 年至 2007 年期间在前瞻性 GRACE 研究中因心脏生物标志物升高和/或 ST 段偏移而就诊的加拿大 NSTE-ACS 患者。我们根据管理策略（非侵入性与侵入性）和低危（GRACE 风险评分≤108）、中危（109-140）和高危（>141）将研究人群进行分层。

结果

总体而言，3893 例患者（67.1%）在入院后 24 小时内接受了早期（<24 小时）抗血小板治疗；低危、中危和高危组的使用比例分别为 76%、73%和 57%（趋势 P<.001）。仅 54%的保守治疗患者和 12%的侵入性治疗患者接受了早期氯吡格雷和 GPIIb/IIIa 抑制剂治疗。高危患者接受早期氯吡格雷或 GPIIb/IIIa 抑制剂治疗的可能性较小（校正比值比=0.48，95%CI 0.39-0.59，P<.001），而院内导管插入术是其独立的阳性预测因子（校正比值比=2.02，95%CI 1.74-2.34，P<.001）。

结论

在这个当代 NSTE-ACS 人群中，氯吡格雷和 GPIIb/IIIa 抑制剂都针对接受侵入性治疗策略的患者使用，但却反常地针对风险较低的患者。特别是，尽管氯吡格雷已被证明有效，但在保守治疗的患者中其使用似乎不足，而高风险、心脏标志物升高的患者中仅少数接受了 GPIIb/IIIa 抑制剂治疗。我们的研究结果强调了在 NSTE-ACS 高危患者中，需要继续推广使用基于证据的抗血小板治疗。