Petricevic Mate, Biocina Bojan, Konosic Sanja, Kopjar Tomislav, Kunac Nino, Gasparovic Hrvoje
Department of Cardiac Surgery, School of Medicine, University of Zagreb, Zagreb, Croatia.
Heart Vessels. 2013 Jan;28(1):57-65. doi: 10.1007/s00380-011-0216-3. Epub 2011 Dec 28.
Residual platelet reactivity (RPR) following coronary artery bypass grafting (CABG) might be related to thrombotic complications and major ischemic cardiac events. The aim of this study was to evaluate the changes in platelet reactivity monitored pre- and postoperatively using multiple-electrode aggregometry (MEA) and to propose an alternative therapeutic approach in a subgroup of patients with postoperative RPR. Ninety-nine patients undergoing elective CABG were enrolled in the study, of whom 41 (41.4%) were diabetic. Preoperatively, all patients received 100 mg acetylsalicylic acid (ASA), with 47 of 99 (47.4%) patients receiving an additional 75 mg clopidogrel (CLO). The blood samples were drawn the day before surgery, and on the first and 4th postoperative day. Platelet count and fibrinogen level were documented, as well as type and daily dose of antiplatelet therapy (APT) received pre- and postoperatively. Multiple-electrode aggregometry using tests based on arachidonic acid (ASPI test) and adenosine diphosphate (ADP test) was performed on the day before and 4 days after surgery. Preoperatively, we detected 31 of 99 (31.3%) patients with RPR (ASPI > 30 AUC). Platelet count correlated with both the ASPI (P = 0.03) and ADP (0.002) tests. Fibrinogen correlated with ADP test values (P < 0.001) and was found to have a higher level in the diabetic subgroup (P = 0.01). In comparison with preoperative results, we detected higher values of ASPI test postoperatively (P = 0.04), with 46 of 99 (46.5%) patients having RPR despite a higher dose of 300 mg ASA being administered. Postoperatively, diabetic patients had higher ASPI test values (P = 0.01), and a higher proportion of patients with RPR compared with the nondiabetic subgroup (58.5 vs 38%, P = 0.04). The subgroup of patients with detected ASPI >30 AUC at the 4th postoperative day consequently received as a part of our clinical routine an additional 75 mg CLO per day, in terms of platelet inhibition optimization. Multiple-electrode aggregometry can recognize patients with RPR during both the pre- and post-CABG period. Postoperatively administered ASA (300 mg) did not sufficiently inhibit platelet aggregation in 46.5% of post-CABG patients. In this group of patients a switch to dual APT should be considered.
冠状动脉旁路移植术（CABG）后残余血小板反应性（RPR）可能与血栓形成并发症和主要缺血性心脏事件有关。本研究的目的是评估使用多电极聚集法（MEA）在术前和术后监测的血小板反应性变化，并为术后RPR患者亚组提出一种替代治疗方法。99例行择期CABG的患者纳入本研究，其中41例（41.4%）为糖尿病患者。术前，所有患者均接受100mg阿司匹林（ASA），99例患者中有47例（47.4%）额外接受75mg氯吡格雷（CLO）。在手术前一天、术后第1天和第4天采集血样。记录血小板计数和纤维蛋白原水平，以及术前和术后接受的抗血小板治疗（APT）的类型和每日剂量。在手术前一天和术后4天进行基于花生四烯酸的检测（ASPI试验）和二磷酸腺苷（ADP试验）的多电极聚集法检测。术前，我们在99例患者中检测到31例（31.3%）RPR患者（ASPI>30 AUC）。血小板计数与ASPI试验（P = 0.03）和ADP试验（P = 0.002）均相关。纤维蛋白原与ADP试验值相关（P < 0.001），并且在糖尿病亚组中发现其水平更高（P = 0.01）。与术前结果相比，我们术后检测到ASPI试验值更高（P = 0.04），尽管给予了更高剂量的300mg ASA，但99例患者中有46例（46.5%）仍有RPR。术后，糖尿病患者的ASPI试验值更高（P = 0.01），与非糖尿病亚组相比，RPR患者比例更高（58.5%对38%，P = 0.04）。因此，术后第4天检测到ASPI>30 AUC的患者亚组在我们的临床常规治疗中每天额外接受75mg CLO，以优化血小板抑制。多电极聚集法可以在CABG术前和术后期间识别RPR患者。术后给予的ASA（300mg）在46.5%的CABG术后患者中未能充分抑制血小板聚集。在这组患者中，应考虑改用双重APT治疗。
