Cecchi Emanuele, Marcucci Rossella, Chiostri Marco, Mecarocci Valerio, Spini Valentina, Innocenti Lisa, Calabretta Raffaella, Cordisco Antonella, Romano Salvatore Mario, Abbate Rosanna, Gensini Gian Franco, Giglioli Cristina
Dipartimento del Cuore e dei Vasi, Azienda Ospedaliero-Universitaria Careggi, Viale Morgagni 85, 50134, Florence, Italy.
Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy.
Intern Emerg Med. 2015 Oct;10(7):805-14. doi: 10.1007/s11739-015-1242-4. Epub 2015 May 6.
Patients' response to dual antiplatelet therapy (DAPT) is subject to variations and its monitoring allows to individualize this therapy. In this study, we evaluated if a strategy of tailored DAPT after platelet function testing could reduce high on-treatment platelet reactivity (HPR) and improve outcome of patients treated with stent implantation. In 257 patients undergoing percutaneous angioplasty, platelet function was measured by light transmittance aggregometry (LTA) using 10 µM/L adenosine-diphosphate (ADP) and 1 mM arachidonic acid (AA) as agonists. Patients with HPR by ADP (≥70%) were switched to double-dose clopidogrel, ticlopidine, prasugrel or ticagrelor; in patients with HPR by AA (≥20%) acetylsalicylic acid dose was increased if not contraindicated. Platelet function analysis was repeated 48 hours after therapy variation. At 20-month follow-up major adverse cardiovascular events (MACE) and bleedings were assessed. HPR was detected in 97/257 (37.7%) patients: 69/257 (26.8%) had HPR by ADP and 71/257 (27.6%) had HPR by AA. In patients with HPR by ADP or by AA, tailored DAPT determined a significant reduction in residual platelet reactivity. No significant difference in MACE or bleeding occurrence was documented in HPR patients treated with tailored DAPT vs. those without HPR. HPR patients treated with tailored DAPT had significant lower follow-up MACE and deaths vs. 139 HPR patients not switched, even after propensity score analysis. These results suggest that a DAPT tailored on platelet testing can improve antiplatelet response in HPR patients, possibly reducing their thrombotic events to a level similar to non-HPR patients, without increasing the risk of bleeding.
患者对双联抗血小板治疗（DAPT）的反应存在差异，对其进行监测有助于实现该治疗的个体化。在本研究中，我们评估了血小板功能检测后进行个体化DAPT策略是否能降低治疗期间的高血小板反应性（HPR）并改善接受支架植入治疗患者的预后。在257例行经皮血管成形术的患者中，使用10µM/L二磷酸腺苷（ADP）和1mM花生四烯酸（AA）作为激动剂，通过透光率聚集法（LTA）测量血小板功能。ADP诱导的HPR（≥70%）患者换用双倍剂量氯吡格雷、噻氯匹定、普拉格雷或替格瑞洛；AA诱导的HPR（≥20%）患者在无禁忌证时增加阿司匹林剂量。治疗调整48小时后重复血小板功能分析。在20个月的随访中评估主要不良心血管事件（MACE）和出血情况。97/257（37.7%）例患者检测到HPR：69/257（26.8%）例患者ADP诱导的HPR，71/257（27.6%）例患者AA诱导的HPR。在ADP或AA诱导的HPR患者中，个体化DAPT使残余血小板反应性显著降低。在接受个体化DAPT治疗的HPR患者与未发生HPR的患者之间，MACE或出血发生率无显著差异。即使经过倾向评分分析，接受个体化DAPT治疗的HPR患者随访期间MACE和死亡发生率也显著低于139例未换药的HPR患者。这些结果表明，基于血小板检测的DAPT可改善HPR患者的抗血小板反应，可能将其血栓形成事件降低至与非HPR患者相似的水平，且不增加出血风险。
