Dalby Anthony J, Gottlieb Shmuel, Cyr Derek D, Magnus Ohman Erik, McGuire Darren K, Ruzyllo Witold, Bhatt Deepak L, Wiviott Stephen D, Winters Kenneth J, Fox Keith A A, Armstrong Paul W, White Harvey D, Prabhakaran Dorairaj, Roe Matthew T
Milpark Hospital, Johannesburg, South Africa.
Department of Cardiology, Shaare Zedek Medical Center, Jerusalem, Israel.
Am Heart J. 2017 Jun;188:156-166. doi: 10.1016/j.ahj.2017.03.015. Epub 2017 Mar 27.
Patients with diabetes mellitus (DM) presenting with acute coronary syndrome (ACS) and undergoing percutaneous coronary intervention (PCI) derived enhanced benefit with dual antiplatelet therapy (DAPT) with prasugrel vs. clopidogrel. The risk profile and treatment response to DAPT for medically managed ACS patients with DM remains uncertain.
The TRILOGY ACS trial compared aspirin + prasugrel vs. aspirin + clopidogrel for up to 30months in non-ST-segment elevation (NSTE) ACS patients managed medically without revascularization. We compared treatment-related outcomes among 3539 patients with DM vs. 5767 patients without DM. The primary endpoint was a composite of cardiovascular death, myocardial infarction, or stroke.
Patients with vs. without DM were younger, more commonly female, heavier, and more often had revascularization prior to the index ACS event. The frequency of the primary endpoint through 30months was higher among patients with vs. without DM (24.8% vs. 16.3%), with a higher risk for those patients with DM treated with insulin vs. those treated without insulin (35.3% vs. 19.9%). There was no significant difference in the frequency of the primary endpoint by treatment with prasugrel vs. clopiodgrel in those with or without DM (P=0.82) and with or without insulin treatment among those with DM (P=0.304).
Among NSTE ACS patients managed medically without revascularization, patients with DM had a higher risk of ischemic events that was amplified among those treated with insulin. There was no differential treatment effect with a more potent DAPT regimen of aspirin + prasugrel vs. aspirin + clopidogrel.
患有糖尿病（DM）且出现急性冠状动脉综合征（ACS）并接受经皮冠状动脉介入治疗（PCI）的患者，与使用氯吡格雷相比，使用普拉格雷的双重抗血小板治疗（DAPT）能带来更大益处。对于接受药物治疗的ACS糖尿病患者，其风险特征和对DAPT的治疗反应仍不确定。
TRILOGY ACS试验比较了阿司匹林+普拉格雷与阿司匹林+氯吡格雷在非ST段抬高（NSTE）ACS患者中长达30个月的治疗效果，这些患者接受药物治疗而非血运重建。我们比较了3539例糖尿病患者与5767例非糖尿病患者的治疗相关结局。主要终点是心血管死亡、心肌梗死或中风的复合终点。
患有糖尿病的患者与未患糖尿病的患者相比，更年轻，女性更常见，体重更重，并且在首次ACS事件之前更常进行血运重建。在30个月时，患有糖尿病的患者中主要终点的发生率高于未患糖尿病的患者（24.8%对16.3%），与未接受胰岛素治疗的糖尿病患者相比，接受胰岛素治疗的患者风险更高（35.3%对19.9%）。在患有或未患糖尿病的患者中，使用普拉格雷与氯吡格雷治疗的主要终点发生率无显著差异（P=0.82），在患有糖尿病的患者中，无论是否接受胰岛素治疗，主要终点发生率也无显著差异（P=0.304）。
在接受药物治疗而非血运重建的NSTE ACS患者中，糖尿病患者发生缺血事件的风险更高，在接受胰岛素治疗的患者中这一风险进一步增加。阿司匹林+普拉格雷与阿司匹林+氯吡格雷这种更强效的DAPT方案没有差异治疗效果。
