不同抗栓治疗方案治疗急性冠脉综合征合并慢性肾脏病患者基线升高的肌钙蛋白的预后意义：来自 ACUITY 试验的一项亚研究。

Prognostic significance of elevated baseline troponin in patients with acute coronary syndromes and chronic kidney disease treated with different antithrombotic regimens: a substudy from the ACUITY trial.

机构信息

Cardiovascular Research Foundation, New York, NY 10022, USA.

出版信息

Circ Cardiovasc Interv. 2012 Apr;5(2):157-65. doi: 10.1161/CIRCINTERVENTIONS.111.963876. Epub 2012 Feb 21.

DOI:10.1161/CIRCINTERVENTIONS.111.963876

PMID:22354934

Abstract

BACKGROUND

Elevation of baseline cardiac troponin in patients presenting with acute coronary syndromes (ACS) confers an adverse prognosis. The prognostic value of troponin elevation in patients with chronic kidney disease (CKD) and ACS is less certain.

METHODS AND RESULTS

In the ACUITY (Acute Catheterization and Urgent Intervention Triage strategy) trial, 13 819 patients with moderate and high-risk ACS were assigned randomly to receive heparin plus a glycoprotein IIb/IIIa inhibitor (GPI), bivalirudin plus a GPI, or bivalirudin monotherapy. Among 2179 patients with CKD (creatinine clearance <60 mL/min), baseline troponin elevation was present in 1291 patients (59.2%). Major bleeding and major adverse cardiac events (MACE), including death, myocardial infarction (MI), or unplanned revascularization, were examined according to baseline troponin status and randomization arm. Patients with CKD in whom the baseline troponin level was elevated had significantly higher rates of death, MI, and MACE at 30 days and 1 year compared with CKD patients without elevated baseline troponin. By multivariable analysis, baseline troponin elevation in patients with CKD was an independent predictor of composite death or MI at 30 days (hazard ratio [95% CI]=2.05 [1.48, 2.83], P<0.0001) and 1 year (1.72 [1.36, 2.17], P<0.0001). In CKD patients with baseline troponin elevation, bivalirudin monotherapy compared with heparin plus a GPI significantly reduced the 30-day rates of major bleeding with nonsignificantly different rates of MACE at 30 days and 1 year.

CONCLUSIONS

In patients with ACS and CKD, baseline troponin elevation is associated with significantly worse short- and long-term clinical outcomes. Bivalirudin monotherapy safely reduces major bleeding in ACS patients with CKD and baseline troponin elevation.

CLINICAL TRIAL REGISTRATION

URL: http://www.clinicaltrials.gov. Unique identifier: NCT00093158.

摘要

背景

患有急性冠状动脉综合征（ACS）的患者基线心脏肌钙蛋白升高预示着不良预后。患有慢性肾脏病（CKD）和 ACS 的患者肌钙蛋白升高的预后价值尚不确定。

方法和结果

在 ACUITY（急性血管造影和紧急介入治疗策略）试验中，13819 名中高危 ACS 患者被随机分配接受肝素加糖蛋白 IIb/IIIa 抑制剂（GPI）、比伐卢定加 GPI 或比伐卢定单药治疗。在 2179 名 CKD 患者（肌酐清除率 <60 mL/min）中，1291 名患者（59.2%）基线肌钙蛋白升高。根据基线肌钙蛋白状态和随机分组臂，检查主要出血和主要不良心脏事件（MACE），包括死亡、心肌梗死（MI）或计划外血运重建。与基线肌钙蛋白无升高的 CKD 患者相比，基线肌钙蛋白升高的 CKD 患者在 30 天和 1 年时的死亡率、MI 和 MACE 发生率明显更高。通过多变量分析，CKD 患者基线肌钙蛋白升高是 30 天复合死亡或 MI 的独立预测因素（风险比[95%CI] = 2.05[1.48,2.83]，P<0.0001）和 1 年（1.72[1.36,2.17]，P<0.0001）。在基线肌钙蛋白升高的 CKD 患者中，与肝素加 GPI 相比，比伐卢定单药治疗可显著降低 30 天主要出血发生率，30 天和 1 年时 MACE 发生率无显著差异。