Division of Cardiovascular Surgery, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, South Korea.
Department of Thoracic and Cardiovascular Surgery, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea.
Am Heart J. 2014 Jun;167(6):818-25. doi: 10.1016/j.ahj.2014.01.016. Epub 2014 Mar 1.
Dual antiplatelet therapy with aspirin and clopidogrel is currently recommended in off-pump coronary artery bypass (OPCAB). However, no data exist concerning platelet reactivity on clopidogrel after OPCAB. The aim of this study was to assess the relationship between platelet reactivity and late major adverse cardiovascular events (MACEs) after OPCAB.
In this prospective, single-center, observational study, on-clopidogrel platelet reactivity was measured using a point-of-care assay (VerifyNow system; Accumetrics Inc, San Diego, CA) in 859 patients who underwent OPCAB with 1 or more vein grafts. The primary end point was late MACEs (30 days-1 year) including cardiac death, nonfatal myocardial infarction, and target vessel revascularization. Receiver operating characteristic curve analysis was used to estimate the cutoff value of P2Y12 reaction units (PRUs) for MACEs.
The optimal cutoff value for posttreatment reactivity for the incidence of late MACEs was ≥188 PRU (area under the curve 0.72, 95% CI 0.68-0.75, P = .002). The incidence of late MACEs was significantly higher in the high platelet reactivity (HPR; ≥188 PRU) group than in the low platelet reactivity (<188 PRU) group (3.6% vs. 1.4%, P = .040). Kaplan-Meier analysis revealed 1-year MACE-free survival rates of 98.4% ± 0.5% and 95.9% ± 1.3% in the low platelet reactivity and HPR groups, respectively (P = .034). According to a Cox regression hazard model, HPR was an independent risk factor for late MACE-free survival (hazard ratio 3.51, 95% CI 1.27-9.69, P = .015).
High residual platelet reactivity after clopidogrel administration is strongly associated with 1-year MACE-free survival. Routine measurement of platelet reactivity and thorough monitoring of patients with HPR after OPCAB are warranted.
目前建议在非体外循环冠状动脉旁路移植术（OPCAB）中使用阿司匹林和氯吡格雷双联抗血小板治疗。然而，OPCAB 后氯吡格雷的血小板反应性尚无数据。本研究旨在评估 OPCAB 后血小板反应性与晚期主要不良心血管事件（MACEs）之间的关系。
在这项前瞻性、单中心、观察性研究中，对 859 例行 OPCAB 并使用 1 个或多个静脉移植物的患者，使用即时检验试剂盒（Accumetrics 公司的 VerifyNow 系统）测定氯吡格雷后的血小板反应性。主要终点是晚期 MACEs（30 天至 1 年），包括心源性死亡、非致死性心肌梗死和靶血管血运重建。使用受试者工作特征曲线分析来估计 MACEs 的 P2Y12 反应单位（PRUs）的截断值。
晚期 MACEs 发生率的最佳治疗后反应性截断值为≥188 PRU（曲线下面积为 0.72，95%CI 为 0.68-0.75，P =.002）。高血小板反应性（HPR；≥188 PRU）组的晚期 MACEs 发生率明显高于低血小板反应性（<188 PRU）组（3.6%比 1.4%，P =.040）。Kaplan-Meier 分析显示，低血小板反应性和 HPR 组的 1 年无 MACE 生存率分别为 98.4%±0.5%和 95.9%±1.3%（P =.034）。根据 Cox 回归风险模型，HPR 是晚期无 MACE 生存率的独立危险因素（危险比为 3.51，95%CI 为 1.27-9.69，P =.015）。
氯吡格雷给药后残留的血小板反应性高与 1 年无 MACE 生存率密切相关。在 OPCAB 后，有必要常规测量血小板反应性并对 HPR 患者进行彻底监测。
