来自大型全人群注册研究的药物洗脱支架血栓形成的固定和可改变相关因素：ADAPT-DES研究的见解
Fixed and Modifiable Correlates of Drug-Eluting Stent Thrombosis From a Large All-Comers Registry: Insights From ADAPT-DES.
作者信息
Brodie Bruce R, Garg Ankit, Stuckey Thomas D, Kirtane Ajay J, Witzenbichler Bernhard, Maehara Akiko, Weisz Giora, Rinaldi Michael J, Neumann Franz-Josef, Metzger D Christopher, Mehran Roxana, Parvataneni Rupa, Stone Gregg W
机构信息
From LeBauer Cardiovascular Research Foundation/Cone Health, Heart and Vascular Center, LeBauer Cardiovascular Research Foundation/Cone Health, Greensboro, NC (B.R.B., T.D.S.); University of North Carolina Internal Medicine Teaching Program, Department of Internal Medicine, Greensboro, NC (A.G.); Center for Interventional Vascular Therapy, Division of Cardiology, NewYork-Presbyterian Hospital/Columbia University Medical Center, New York, NY (A.J.K., A.M., G.W., G.W.S.); Clinical Trials Center, Cardiovascular Research Foundation, New York, NY (A.J.K., A.M., G.W., R.M., R.P., G.W.S.); Department of Cardiology and Pneumology, Helios Amper-Klinikum, Dachau, Germany (B.W.); Els & Charles Bendheim Department of Cardiology, Shaare Zedek Medical Center, Jerusalem, Israel (G.W.); Sanger Heart & Vascular Institute, Charlotte, NC (M.J.R.); Department of Cardiology and Angiology II, Universitäts-Herzzentrum Freiburg Bad Krozingen, Bad Krozingen, Germany (F.-J.N.); Wellmont CVA Heart Institute, Kingsport, TN (D.C.M.); and The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY (R.M.).
出版信息
Circ Cardiovasc Interv. 2015 Oct;8(10). doi: 10.1161/CIRCINTERVENTIONS.114.002568.
BACKGROUND
Previous studies evaluating correlates of stent thrombosis (ST) have included mostly patients with bare metal stents and early-generation drug-eluting stents (DES) and have not systematically evaluated the role of intravascular ultrasound-guided stenting and high platelet reactivity on clopidogrel. The purpose of this study was to evaluate the frequency and correlates of ST in patients receiving DES, specifically examining the impact of risk factors modifiable by physician and patient behavior.
METHODS AND RESULTS
Assessment of Dual Anti-platelet Therapy With Drug-Eluting Stents (ADAPT-DES) was a multicenter, prospective study in patients undergoing successful coronary intervention with DES in whom routine platelet reactivity testing was performed. Definite or probable ST occurred in 92 (1.1%) of 8582 patients within 2 years. Independent baseline correlates of ST included presentation with an acute coronary syndrome (hazard ratio [HR]=1.81, P=0.01), insulin-treated diabetes mellitus (HR=1.91, P=0.02), previous myocardial infarction (HR=1.75, P=0.02), and peripheral arterial disease (HR=2.01, P=0.01). Independent treatment-related correlates included use of early generation DES (HR=1.75, P=0.02), no procedural intravascular ultrasound guidance (HR=1.75, P=0.04), and premature discontinuation of dual antiplatelet therapy (HR=2.67, P=0.003); high platelet reactivity on clopidogrel trended as a correlate of ST (HR=1.49, P=0.08). The 2-year risk of ST ranged from 0.3% to 10.0% when 0 to 3 modifiable risk factors were present.
CONCLUSIONS
After successful DES implantation, ST occurred within 2 years in 1.1% of patients and was strongly associated with fixed and modifiable risk factors. The frequency of ST may be reduced with intravascular ultrasound -guided stenting, assiduous adherence to dual antiplatelet therapy, and adequate P2Y12 platelet receptor inhibition.
CLINICAL TRIAL REGISTRATION
URL: http://www.clinicaltrials.gov. Unique identifier: NCT00638794.
背景
既往评估支架内血栓形成（ST）相关因素的研究大多纳入的是接受裸金属支架和早期药物洗脱支架（DES）的患者，且未系统评估血管内超声引导下支架置入术以及氯吡格雷抵抗状态下高血小板反应性的作用。本研究旨在评估接受DES治疗患者中ST的发生率及其相关因素，特别探讨可通过医生和患者行为改变的危险因素的影响。
方法与结果
药物洗脱支架双重抗血小板治疗评估（ADAPT-DES）是一项多中心前瞻性研究，纳入成功接受DES冠状动脉介入治疗且进行常规血小板反应性检测的患者。8582例患者中，92例（1.1%）在2年内发生明确或可能的ST。ST的独立基线相关因素包括急性冠状动脉综合征表现（风险比[HR]=1.81，P=0.01）、胰岛素治疗的糖尿病（HR=1.91，P=0.02）、既往心肌梗死（HR=1.75，P=0.02）和外周动脉疾病（HR=2.01，P=0.01）。独立的治疗相关因素包括使用早期DES（HR=1.75，P=0.02）、无术中血管内超声引导（HR=1.75，P=0.04）和过早停用双重抗血小板治疗（HR=2.67，P=0.003）；氯吡格雷抵抗状态下的高血小板反应性有成为ST相关因素的趋势（HR=1.49，P=0.08）。存在0至3个可改变危险因素时，2年ST风险为0.3%至10.0%。
结论
DES成功植入后，1.1%的患者在2年内发生ST，且与固定和可改变的危险因素密切相关。血管内超声引导下支架置入术、严格坚持双重抗血小板治疗以及充分抑制P2Y12血小板受体可降低ST的发生率。
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