外周动脉疾病患者冠状动脉植入药物洗脱支架后的血小板反应性及临床结局：来自ADAPT-DES研究（药物洗脱支架双重抗血小板治疗评估）的分析
Platelet Reactivity and Clinical Outcomes After Coronary Artery Implantation of Drug-Eluting Stents in Subjects With Peripheral Arterial Disease: Analysis From the ADAPT-DES Study (Assessment of Dual Antiplatelet Therapy With Drug-Eluting Stents).
作者信息
Gupta Rajesh, Kirtane Ajay J, Ozan M Ozgu, Witzenbichler Bernhard, Rinaldi Michael J, Metzger D Christopher, Weisz Giora, Stuckey Thomas D, Brodie Bruce R, Mehran Roxana, Ben-Yehuda Ori, Stone Gregg W
机构信息
From the University of Toledo Medical Center, OH (R.G.); Cardiovascular Research Foundation, New York, NY (A.J.K., M.O.O., G.W., R.M., O.B.-Y., G.W.S.); NewYork-Presbyterian Hospital/Columbia University Medical Center, NY (A.J.K., G.W., O.B.-Y., G.W.S.); Helios Amper-Klinikum, Dachau, Germany (B.W.); Sanger Heart & Vascular Institute/Carolinas HealthCare System, Charlotte, NC (M.J.R.); Wellmont CVA Heart Institute, Kingsport, TN (D.C.M.); Shaare Zedek Medical Center, Jerusalem, Israel (G.W.); LeBauer-Brodie Center for Cardiovascular Research and Education/Cone Health, Greensboro, NC (T.D.S., B.R.B.); and Icahn School of Medicine at Mount Sinai, New York, NY (R.M.).
出版信息
Circ Cardiovasc Interv. 2017 Mar;10(3). doi: 10.1161/CIRCINTERVENTIONS.116.004904.
BACKGROUND
Patients with peripheral arterial disease (PAD) have high rates of adverse cardiovascular events after percutaneous coronary intervention and may additionally have heightened platelet reactivity. This study assessed the relationship between platelet reactivity and clinical outcomes after percutaneous coronary interventions among subjects with and without PAD.
METHODS AND RESULTS
ADAPT-DES (Assessment of Dual Antiplatelet Therapy With Drug-Eluting Stents) was a prospective, multicenter registry of patients treated with coronary drug-eluting stents. Platelet reactivity was assessed by the VerifyNow point-of-care assay; high on-treatment platelet reactivity (HPR) was defined as P2Y12 reaction units >208. A propensity-adjusted multivariable analysis was performed to determine the relationship between PAD, platelet reactivity, and subsequent adverse events (definite or probable stent thrombosis, all-cause mortality, myocardial infarction, and clinically relevant bleeding). Among 8582 patients, 10.2% had a history of PAD. Patients with PAD were older and more likely to have comorbid conditions; however, mean P2Y12 reaction units and HPR were not significantly different between PAD and no PAD groups. Patients with PAD had higher 2-year rates of all-cause mortality, myocardial infarction, stent thrombosis, and clinically relevant bleeding. Associations between HPR and adverse events were similar in PAD and no PAD groups, without evidence of interaction; however, adverse event rates were highest among subjects with both PAD and HPR. In a propensity-adjusted multivariable model, both PAD and HPR were independent predictors of myocardial infarction at 2 years.
CONCLUSIONS
A history of PAD was associated with ischemic and bleeding outcomes 2 years after successful coronary drug-eluting stent implantation; however, these associations did not seem to be directly mediated by heightened platelet reactivity.
CLINICAL TRIAL REGISTRATION
URL: http://www.clinicaltrials.gov. Unique identifier: NCT00638794.
背景
外周动脉疾病（PAD）患者在经皮冠状动脉介入治疗后发生不良心血管事件的几率较高，并且可能还存在血小板反应性增强的情况。本研究评估了伴有和不伴有PAD的受试者经皮冠状动脉介入治疗后血小板反应性与临床结局之间的关系。
方法与结果
ADAPT-DES（药物洗脱支架双重抗血小板治疗评估）是一项针对接受冠状动脉药物洗脱支架治疗患者的前瞻性多中心注册研究。通过即时检验的VerifyNow分析法评估血小板反应性；治疗中高血小板反应性（HPR）定义为P2Y12反应单位>208。进行倾向调整多变量分析以确定PAD、血小板反应性与随后不良事件（明确或可能的支架血栓形成、全因死亡率、心肌梗死和临床相关出血）之间的关系。在8582例患者中，10.2%有PAD病史。患有PAD的患者年龄更大，更可能有合并症；然而，PAD组和无PAD组之间的平均P2Y12反应单位和HPR并无显著差异。患有PAD的患者全因死亡率、心肌梗死、支架血栓形成和临床相关出血的2年发生率更高。PAD组和无PAD组中HPR与不良事件之间的关联相似，无相互作用的证据；然而，同时患有PAD和HPR的受试者不良事件发生率最高。在倾向调整多变量模型中，PAD和HPR均是2年时心肌梗死的独立预测因素。
结论
PAD病史与冠状动脉药物洗脱支架成功植入后2年的缺血和出血结局相关；然而，这些关联似乎并非直接由血小板反应性增强介导。
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