旁路手术后氯吡格雷联合阿司匹林与单独应用阿司匹林对原发性冠状动脉疾病进展的影响：来自 Clopidogrel After Surgery for Coronary Artery DiseasE（CASCADE）随机试验的分析。
Impact of clopidogrel plus aspirin versus aspirin alone on the progression of native coronary artery disease after bypass surgery: analysis from the Clopidogrel After Surgery for Coronary Artery DiseasE (CASCADE) randomized trial.
机构信息
From the Division of Cardiac Surgery (D.U., T.A.-A., M.R.) and Division of Cardiology (M.L.M.), University of Ottawa Heart Institute, Ottawa, Ontario, Canada; Lynn Heart and Vascular Institute, Boca Raton, FL (A.K.); Division of Cardiac Surgery, Hôpital Laval, Quebec City, Quebec, Canada (P.V.); and Department of Epidemiology and Community Medicine, University of Ottawa, Ottawa, Ontario, Canada (M.R.).
出版信息
Circulation. 2014 Sep 9;130(11 Suppl 1):S12-8. doi: 10.1161/CIRCULATIONAHA.113.008227.
BACKGROUND
The effects of dual antiplatelet therapy with aspirin and clopidogrel on the progression of native coronary artery disease after coronary artery bypass grafting are unknown.
METHODS AND RESULTS
In the Clopidogrel After Surgery for Coronary Artery DiseasE (CASCADE) trial, a total of 113 patients were randomized to receive aspirin plus clopidogrel or aspirin plus placebo for 1 year after coronary artery bypass grafting. In this secondary analysis, the 92 patients who underwent preoperative and 1-year postoperative angiograms at 2 centers had each of their coronary stenoses graded serially by using 6 thresholds (grade 0 [0%-24%], grade 1 [25%-37%], grade 2 [38%-62%], grade 3 [63%-82%], grade 4 [83%-98%], and grade 5 [99%-100%]). We compared the incidence and degree of evolving coronary artery disease between the 2 treatment groups. A total of 543 preoperative stenoses and occlusions were quantified and followed. At 1-year postoperatively, there were 103 evolving (94 worsened, 9 improved) and 22 new lesions. The right coronary artery territory and sites proximal to a graft were more commonly associated with worsening coronary artery disease (P≤0.02). There were no differences in clinical events between treatment groups, and the proportion of patients with evolving or new lesions was also similar (70% versus 74%, aspirin-clopidogrel versus aspirin-placebo, respectively; P=0.8). However, in evolving or new lesions, the mean grade change (1.1±1.0 versus 1.6±1.1, respectively; P=0.01) and the proportion of new occlusions (7% versus 22%; P=0.02) were lower in the aspirin-clopidogrel group.
CONCLUSIONS
The addition of clopidogrel to aspirin correlates with less worsening of native coronary artery disease 1 year after coronary artery bypass grafting. These findings may help guide post-coronary artery bypass grafting antiplatelet therapy.
CLINICAL TRIAL REGISTRATION URL
http://www.clinicaltrials.gov. Unique identifier: NCT00228423.
背景
在冠状动脉旁路移植术后，双重抗血小板治疗（阿司匹林和氯吡格雷）对原发性冠状动脉疾病进展的影响尚不清楚。
方法和结果
在 Clopidogrel After Surgery for Coronary Artery DiseasE（CASCADE）试验中，共 113 名患者被随机分为阿司匹林加氯吡格雷组或阿司匹林加安慰剂组，在冠状动脉旁路移植术后 1 年进行治疗。在这项二次分析中，在 2 个中心进行术前和 1 年随访血管造影的 92 名患者，他们的每条冠状动脉狭窄程度分别使用 6 个阈值（0 级[0%至 24%]、1 级[25%至 37%]、2 级[38%至 62%]、3 级[63%至 82%]、4 级[83%至 98%]和 5 级[99%至 100%]）进行连续分级。我们比较了两组治疗之间新发和进展性冠状动脉疾病的发生率和程度。共量化和随访了 543 个术前狭窄和闭塞部位。术后 1 年时，有 103 个部位发生进展（94 个恶化，9 个改善）和 22 个新病变。右冠状动脉和吻合部位近端更容易出现冠状动脉疾病恶化（P≤0.02）。两组之间的临床事件没有差异，进展或新发病变的患者比例也相似（阿司匹林-氯吡格雷组 70%，阿司匹林-安慰剂组 74%；P=0.8）。然而，在进展或新发病变中，阿司匹林-氯吡格雷组的平均病变程度变化（1.1±1.0 比 1.6±1.1；P=0.01）和新发闭塞的比例（7%比 22%；P=0.02）较低。
结论
与阿司匹林相比，加用氯吡格雷可使冠状动脉旁路移植术后 1 年时原发性冠状动脉疾病恶化程度降低。这些发现可能有助于指导冠状动脉旁路移植术后的抗血小板治疗。
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