University of Florida College of Medicine-Jacksonville, Jacksonville, Florida; Heart Diseases Institute, Hospital Universitari de Bellvitge-IDIBELL, University of Barcelona, L'Hospitalet de Llobregat, Barcelona, Spain.
VA Boston Healthcare System, Brigham and Women's Hospital, and Harvard Medical School, Boston, Massachusetts.
J Am Coll Cardiol. 2014 Mar 4;63(8):769-77. doi: 10.1016/j.jacc.2013.10.043. Epub 2013 Nov 13.
The goal of this study was to investigate the differential efficacy of clopidogrel or aspirin monotherapy according to smoking status in patients with atherosclerotic vascular disease.
Smoking enhances clopidogrel-induced platelet inhibition, which may explain the higher relative benefit among smokers observed in trials evaluating dual antiplatelet therapy. Whether smoking has an impact on clinical outcomes in patients requiring a single antiplatelet agent remains unknown.
This was a post-hoc analysis of the CAPRIE (Clopidogrel Versus Aspirin in Patients at Risk of Ischemic Events) trial that compared clopidogrel and aspirin monotherapy in patients (N = 19,184) with atherosclerotic vascular disease.
Current smokers (n = 5,688) had an increased risk of ischemic events compared with never smokers (n = 4,135; hazard ratio [HR]: 1.24 [95% confidence interval (CI): 1.08 to 1.42]) and ex-smokers (n = 9,381; HR: 1.32 [95% CI: 1.18 to 1.47]) (p < 0.001). Clopidogrel was associated with a reduction in ischemic events among current smokers (8.3% vs. 10.8%; HR: 0.76 [95% CI: 0.64 to 0.90]), whereas no benefit over aspirin was seen in the combined group of ex-smokers/never-smoked patients (10.4% vs. 10.6%; HR: 0.99 [95% CI: 0.89 to 1.10]; p = 0.01 for interaction). Among current smokers, clopidogrel also reduced myocardial infarction, vascular death, and death from any cause compared with aspirin. No interaction between smoking status and study treatment was observed for bleeding events.
In a post-hoc analysis of the CAPRIE population, current smokers appeared to have enhanced benefit with clopidogrel therapy for secondary prevention compared with aspirin. These results should be considered hypothesis generating for future prospective studies assessing the impact of specific platelet-inhibiting strategies according to smoking status.
本研究旨在探讨在动脉粥样硬化性血管疾病患者中，根据吸烟状态，氯吡格雷或阿司匹林单药治疗的疗效差异。
吸烟增强了氯吡格雷诱导的血小板抑制作用，这可能解释了在评估双联抗血小板治疗的试验中观察到的吸烟者相对获益更高的原因。在需要单一抗血小板药物的患者中，吸烟是否对临床结局有影响仍不清楚。
这是 CAPRIE（氯吡格雷与阿司匹林在缺血事件风险患者中的比较）试验的事后分析，该试验比较了氯吡格雷和阿司匹林在 19184 例动脉粥样硬化性血管疾病患者中的单药治疗。
与从不吸烟者（n=4135；风险比[HR]：1.24[95%置信区间（CI）：1.08 至 1.42]）和戒烟者（n=9381；HR：1.32[95%CI：1.18 至 1.47]）相比，当前吸烟者（n=5688）发生缺血事件的风险增加（p<0.001）。氯吡格雷可降低当前吸烟者的缺血事件发生率（8.3% vs. 10.8%；HR：0.76[95%CI：0.64 至 0.90]），而在戒烟者/从不吸烟者的合并组中，氯吡格雷与阿司匹林相比没有获益（10.4% vs. 10.6%；HR：0.99[95%CI：0.89 至 1.10]；p=0.01 用于交互作用）。在当前吸烟者中，氯吡格雷还降低了心肌梗死、血管死亡和任何原因导致的死亡。吸烟状态和研究治疗之间没有观察到出血事件的相互作用。
在 CAPRIE 人群的事后分析中，与阿司匹林相比，当前吸烟者接受氯吡格雷治疗的二级预防似乎获益更大。这些结果应为未来根据吸烟状态评估特定血小板抑制策略影响的前瞻性研究提供假设。
