Xia Jing-Gang, Qu Yang, Shen Hong, Liu Xiu-Hua
Medical School of Chinese People's Liberation Army, Chinese PLA General Hospital, Beijing, China.
Coron Artery Dis. 2013 Sep;24(6):522-6. doi: 10.1097/MCA.0b013e3283645c79.
Patients with a recently diagnosed ST-elevation myocardial infarction (STEMI) and implanted coronary drug-eluting stent (DES) who need urgent surgery are at increased risk of surgical bleeding unless aspirin and clopidogrel are discontinued beforehand. However, discontinuation of aspirin and clopidogrel is associated with a high rate of recurrent myocardial infarction, heart failure, and malignant arrhythmias because of stent thrombosis. The main point of debate is how to treat these patients. We hypothesized that perioperative intravenous administration of tirofiban, a GPIIb/IIIa inhibitor, would allow the safe withdrawal of aspirin and clopidogrel without increasing the risk of surgical bleeding.
Twenty-one patients implanted with a coronary DES after STEMI who underwent urgent surgery were selected for this clinical trial. Tirofiban was used to replace aspirin and clopidogrel (dual antiplatelet drugs) before and after urgent surgery. Major adverse cardiovascular and bleeding events were observed during hospitalization and within 3 months of discharge.
Twenty-one patients with recently diagnosed STEMI and implanted DES [median (range) 6 (3-8) months] and high-risk characteristics for stent thrombosis underwent urgent major surgery. Tirofiban was used to replace aspirin and clopidogrel 5 days before surgery, stopped 4 h before surgery, and resumed until oral aspirin and clopidogrel was resumed after surgery. There were no deaths, myocardial infarction, stent thrombosis, or surgical re-exploration because of bleeding during hospitalization and within 3 months of discharge. There was one case of acute left ventricular failure during hospitalization.
In patients who need urgent surgery after recently diagnosed STEMI and implanted DES, a strategy using tirofiban may allow temporary withdrawal of dual antiplatelet drugs without increasing the risk of bleeding. This conclusion needs to be further confirmed by large-scale randomized clinical trials.
近期诊断为ST段抬高型心肌梗死（STEMI）且植入冠状动脉药物洗脱支架（DES）的患者，若需紧急手术，除非提前停用阿司匹林和氯吡格雷，否则手术出血风险会增加。然而，停用阿司匹林和氯吡格雷会因支架血栓形成导致心肌梗死复发、心力衰竭和恶性心律失常的发生率很高。主要的争议点在于如何治疗这些患者。我们假设围手术期静脉注射替罗非班（一种糖蛋白IIb/IIIa抑制剂）可在不增加手术出血风险的情况下安全停用阿司匹林和氯吡格雷。
本临床试验选取了21例STEMI后植入冠状动脉DES并接受紧急手术的患者。在紧急手术前后，使用替罗非班替代阿司匹林和氯吡格雷（双联抗血小板药物）。观察住院期间及出院后3个月内的主要不良心血管和出血事件。
21例近期诊断为STEMI且植入DES[中位值（范围）6（3 - 8）个月]且有支架血栓形成高风险特征的患者接受了紧急大手术。替罗非班在手术前5天用于替代阿司匹林和氯吡格雷，手术前4小时停用，术后恢复使用直至重新开始口服阿司匹林和氯吡格雷。住院期间及出院后3个月内，无死亡、心肌梗死、支架血栓形成或因出血而进行的手术再次探查情况。住院期间有1例急性左心室衰竭病例。
在近期诊断为STEMI且植入DES后需要紧急手术的患者中，使用替罗非班的策略可能允许暂时停用双联抗血小板药物而不增加出血风险。这一结论需要通过大规模随机临床试验进一步证实。
