van Diepen Sean, Merrill Peter D, Carrier Michel, Tardif Jean-Claude, Podgoreanu Mihai, Alexander John H, Lopes Renato D
Department of Critical Care and Division of Cardiology, 2C2 Cardiology Walter MacKenzie Center, University of Alberta Hospital, 8440 112th St., Edmonton, AB, T6G 2B7, Canada.
Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC, USA.
J Thromb Thrombolysis. 2017 May;43(4):446-453. doi: 10.1007/s11239-017-1480-6.
Myonecrosis after coronary artery bypass graft (CABG) surgery is associated with excess mortality. Tranexamic acid (TA), an anti-fibrinolytic agent, has been shown to reduce peri-operative blood loss without increasing the risk of myocardial infarction (MI); however, no large study has examined the association between TA treatment and post-CABG myonecrosis. In the MC-1 to Eliminate Necrosis and Damage in Coronary Artery Bypass Graft Surgery II trial, inverse probability weighting of the propensity to receive TA was used to test for differences among the 656 patients receiving and 770 patients not receiving TA. The primary outcome was creatine kinase MB (CK-MB) area under the curve (AUC) through 24 h. The secondary outcome was 30-day cardiovascular death or MI. Patients who received TA were more frequently female, had a previous MI, heart failure, low molecular weight heparin therapy, on-pump CABG, valvular surgery, and saphenous vein or radial grafts. The median 24-h CK-MB AUC was higher in TA-treated patients [301.9 (IQR 196.7-495.6) vs 253.5 (153.4-432.5) ng h/mL, p < 0.001]. No differences in the 30-day incidence of cardiovascular death or MI were observed (8.7 vs 8.3%, adjusted OR 0.99; 95% CI 0.67-1.45, p = 0.948). In patients undergoing CABG, TA use was associated with a higher risk of myonecrosis; however, no differences were observed in death or MI. Future larger studies should be directed at examining the pathophysiology of TA myonecrosis, and its association with subsequent clinical outcomes.
冠状动脉旁路移植术（CABG）后发生的心肌坏死与死亡率过高相关。氨甲环酸（TA）是一种抗纤溶药物，已被证明可减少围手术期失血且不增加心肌梗死（MI）风险；然而，尚无大型研究探讨TA治疗与CABG后心肌坏死之间的关联。在“MC - 1冠状动脉旁路移植手术中消除坏死和损伤II”试验中，采用接受TA倾向的逆概率加权法，对656例接受TA治疗的患者和770例未接受TA治疗的患者进行差异检验。主要结局指标是24小时内肌酸激酶MB（CK - MB）曲线下面积（AUC）。次要结局指标是30天内心血管死亡或心肌梗死。接受TA治疗的患者女性更为常见，既往有心肌梗死、心力衰竭、接受低分子量肝素治疗、在体外循环下进行CABG、接受瓣膜手术以及使用大隐静脉或桡动脉移植物。接受TA治疗的患者24小时CK - MB AUC中位数更高[301.9（四分位间距196.7 - 495.6）对253.5（153.4 - 432.5）ng·h/mL，p < 0.001]。未观察到30天内心血管死亡或心肌梗死发生率的差异（8.7%对8.3%，校正比值比0.99；95%置信区间0.67 - 1.45，p = 0.948）。在接受CABG的患者中，使用TA与更高的心肌坏死风险相关；然而，在死亡或心肌梗死方面未观察到差异。未来应开展更大规模的研究，以探讨TA导致心肌坏死的病理生理学及其与后续临床结局的关联。
