Bagai Akshay, Peterson Eric D, McCoy Lisa A, Effron Mark B, Zettler Marjorie E, Stone Gregg W, Henry Timothy D, Cohen David J, Schulte Phillip J, Anstrom Kevin J, Wang Tracy Y
Terrence Donnelly Heart Center, St Michael's Hospital, University of Toronto, Ontario, Canada.
Duke Clinical Research Institute, Durham, NC.
Am Heart J. 2017 May;187:19-28. doi: 10.1016/j.ahj.2017.02.003. Epub 2017 Feb 10.
Little is known about the use of platelet function testing to guide choice of P2Y receptor inhibitor therapy in routine clinical practice.
We studied 671 myocardial infarction (MI) patients treated with percutaneous coronary intervention in the TRANSLATE-ACS Registry who had VerifyNow platelet function testing performed while on clopidogrel treatment during their index hospitalization (April 2010-October 2012).
High platelet reactivity (>208 platelet reactivity units [PRU]) was present in 261 (38.9%) patients. Clopidogrel was switched in-hospital to prasugrel in 80 (30.7%) patients with high platelet reactivity and 18 (4.4%) patients with therapeutic platelet reactivity (≤208 PRU). Among high platelet reactivity patients, switch to prasugrel was associated with lower major adverse cardiovascular events (death, MI, stroke, or unplanned revascularization) at 1year (10.0% vs 22.7%, P=.02; adjusted odds ratio [OR] 0.39, 95% CI 0.18-0.85, P=.02) and no significant difference in Bleeding Academic Research Consortium type 2 or higher bleeding (23.8% vs 22.1%, P=.77; adjusted OR 0.91, 95% CI 0.48-1.7, P=.77) compared with patients continued on clopidogrel. No significant differences in major adverse cardiovascular event (22.2% vs 12.8%, P=.25; adjusted OR 1.8, 95% CI 0.47-7.3, P=.38) or bleeding (22.2% vs 19.4%, P=.77; adjusted OR 1.3, 95% CI 0.27-6.8, P=.72) were observed among therapeutic platelet reactivity patients between switching and continuation on clopidogrel.
Only one-third of percutaneous coronary intervention-treated MI patients with high on-clopidogrel platelet reactivity were switched to a more potent P2Y receptor inhibitor. Intensification of antiplatelet therapy was associated with lower risk of ischemic events at 1year among HPR patients.
在常规临床实践中，关于使用血小板功能检测来指导P2Y受体抑制剂治疗的选择，人们了解甚少。
我们在TRANSLATE-ACS注册研究中对671例接受经皮冠状动脉介入治疗的心肌梗死（MI）患者进行了研究，这些患者在其首次住院期间（2010年4月至2012年10月）接受氯吡格雷治疗时进行了VerifyNow血小板功能检测。
261例（38.9%）患者存在高血小板反应性（>208血小板反应性单位[PRU]）。80例（30.7%）高血小板反应性患者和18例（4.4%）血小板反应性处于治疗水平（≤208 PRU）的患者在住院期间将氯吡格雷换为普拉格雷。在高血小板反应性患者中，换用普拉格雷与1年时较低的主要不良心血管事件（死亡、心肌梗死、中风或计划外血管重建）发生率相关（10.0%对22.7%，P=0.02；校正比值比[OR]0.39，95%可信区间0.18 - 0.85，P=0.02），与继续使用氯吡格雷的患者相比，2型或更高Bleeding Academic Research Consortium出血发生率无显著差异（23.8%对22.1%，P=0.77；校正OR 0.91，95%可信区间0.48 - 1.7，P=0.77）。在血小板反应性处于治疗水平的患者中，换用与继续使用氯吡格雷相比，主要不良心血管事件（22.2%对12.8%，P=0.25；校正OR 1.8，95%可信区间0.47 - 7.3，P=0.38）或出血发生率（22.2%对19.4%，P=0.77；校正OR 1.3，95%可信区间0.27 - 6.8，P=0.72）均无显著差异。
在接受经皮冠状动脉介入治疗的心肌梗死患者中，只有三分之一氯吡格雷治疗时血小板反应性高的患者换用了更强效的P2Y受体抑制剂。在高血小板反应性患者中，强化抗血小板治疗与1年时较低的缺血事件风险相关。
