Cardiovascular Institute, Mount Sinai Medical Center, One Gustave L. Levy Place, New York, NY 10029, USA.
Circulation. 2011 Apr 26;123(16):1745-56. doi: 10.1161/CIRCULATIONAHA.110.981688. Epub 2011 Apr 11.
Concerns persist regarding the risk of stent thrombosis in the setting of primary percutaneous coronary intervention for ST-segment elevation myocardial infarction.
The Harmonizing Outcomes With Revascularization and Stents in Acute Myocardial Infarction (HORIZONS-AMI) trial included 3602 patients with ST-segment elevation myocardial infarction undergoing primary percutaneous coronary intervention who were randomized to heparin plus a glycoprotein IIb/IIIa inhibitor (GPI) (n=1802) versus bivalirudin monotherapy (n=1800). Stents were implanted in 3202 patients, including 2261 who received drug-eluting stents and 861 who received only bare metal stents. Definite or probable stent thrombosis within 2 years occurred in 137 patients (4.4%), including 28 acute events (0.9%), 49 subacute events (1.6%), 32 late events (1.0%), and 33 very late events (1.1%). The 2-year cumulative rates of stent thrombosis were 4.4% with both drug-eluting stents and bare metal stents (P=0.98) and 4.3% versus 4.6% in patients randomized to bivalirudin monotherapy versus heparin plus a GPI, respectively (P=0.73). Acute stent thrombosis occurred more frequently in patients assigned to bivalirudin compared with heparin plus a GPI (1.4% versus 0.3%; P<0.001), whereas stent thrombosis after 24 hours occurred less frequently in patients with bivalirudin compared with heparin plus a GPI (2.8% versus 4.4%; P=0.02). Pre-randomization heparin and a 600-mg clopidogrel loading dose were independent predictors of reduced acute and subacute stent thrombosis, respectively.
Stent thrombosis is not uncommon within the first 2 years after primary percutaneous coronary intervention in ST-segment elevation myocardial infarction, and occurs with similar frequency in patients receiving drug-eluting stents versus bare metal stents and bivalirudin alone versus heparin plus a GPI. Optimizing adjunct pharmacology including early antithrombin therapy preloading with a potent antiplatelet therapy may further reduce stent thrombosis in ST-segment elevation myocardial infarction.
对于 ST 段抬高型心肌梗死患者行直接经皮冠状动脉介入治疗时的支架血栓形成风险仍存在担忧。
Harmonizing Outcomes With Revascularization and Stents in Acute Myocardial Infarction（HORIZONS-AMI）试验纳入了 3602 例接受直接经皮冠状动脉介入治疗的 ST 段抬高型心肌梗死患者，随机分为肝素联合糖蛋白 IIb/IIIa 抑制剂（GPI）组（n=1802）和比伐卢定单药组（n=1800）。3202 例患者植入支架，其中 2261 例患者植入药物洗脱支架，861 例患者植入仅裸金属支架。2 年内确定或可能的支架血栓形成 137 例（4.4%），其中 28 例为急性事件（0.9%），49 例为亚急性事件（1.6%），32 例为晚期事件（1.0%），33 例为极晚期事件（1.1%）。药物洗脱支架和裸金属支架的 2 年累计支架血栓形成率分别为 4.4%（P=0.98），比伐卢定单药组和肝素联合 GPI 组分别为 4.3%和 4.6%（P=0.73）。与肝素联合 GPI 相比，比伐卢定组的急性支架血栓形成更常见（1.4% vs. 0.3%；P<0.001），而比伐卢定组的支架血栓形成在 24 小时后更少见（2.8% vs. 4.4%；P=0.02）。预先随机化的肝素和 600mg 氯吡格雷负荷剂量是急性和亚急性支架血栓形成的独立预测因素。
ST 段抬高型心肌梗死患者行直接经皮冠状动脉介入治疗后 2 年内支架血栓形成并不少见，且在接受药物洗脱支架和裸金属支架以及比伐卢定单药与肝素联合 GPI 治疗的患者中，其发生频率相似。优化辅助药物治疗，包括早期使用强效抗血小板治疗进行预抗凝治疗，可能进一步降低 ST 段抬高型心肌梗死患者的支架血栓形成。
