Bagai Jayant, Little Bert, Banerjee Subhash
VA Tennessee Valley Health Care System, Vanderbilt University Medical Center, United States, University of Louisville, Louisville, KY, VA North Texas Health Care System and UT Southwestern Medical Center, Dallas, TX.
VA Tennessee Valley Health Care System, Vanderbilt University Medical Center, United States, University of Louisville, Louisville, KY, VA North Texas Health Care System and UT Southwestern Medical Center, Dallas, TX.
Cardiovasc Revasc Med. 2018 Jan-Feb;19(1 Pt B):95-101. doi: 10.1016/j.carrev.2017.06.005. Epub 2017 Jun 8.
Studies have shown reduction in major bleeding with trans-radial intervention (TRI) compared with trans-femoral intervention (TFI), and with use of bivalirudin compared with heparin+glycoprotein IIb/IIIa inhibitors (GPI). We compared major bleeding, mortality and the interaction between arterial access site and the anticoagulant used for PCI in Veterans.
A retrospective cohort of 1192 consecutive patients who underwent PCI at a VA hospital between 2006 and 2012 was divided into TFI-heparin (n=192), TFI-bivalirudin (n=272), TRI-heparin (n=274) and TRI-bivalirudin (n=454) groups. Primary outcomes were in-hospital major bleeding, in-hospital and 1-year all-cause mortality. Secondary outcomes were in-hospital MI, in-hospital and 1-year MACE and net adverse cardiovascular events (NACE - composite of major bleeding+MACE).
Femoral access was associated with a significantly increased risk of major bleeding compared with radial access (OR 11.87, p<0.001). Correspondingly, radial access was protective against major bleeding compared with femoral access (OR 0.128, p<0.01), but did not lower mortality or MACE by itself. Severe anemia was the only predictor of in-hospital all-cause mortality (OR=27.62, p<0.008). Presence of anemia and age>70 predicted 1-year mortality, whereas major bleeding and anemia predicted 1-year MACE. An interaction was noted between anticoagulant and access site, such that heparin showed significantly greater major bleeding in the femoral group compared with the radial group. Bivalirudin resulted in similar risk of bleeding, regardless of access site. There was a synergistic interaction between radial access and heparin (HR 0.38, p<0.05), but not radial access and bivalirudin, on reduction in 1-year NACE.
Radial access for PCI is associated with reduction in major bleeding, but does not have an effect on in-patient or 1-year MACE and mortality. Major bleeding is associated with poor short and intermediate term outcomes. In addition, anemia is strongly associated with increased in-patient and 1-year mortality. There is a differential effect of heparin but not bivalirudin on major bleeding, depending on the access site. There is no synergism between radial access and bivalirudin in lowering the composite outcome of MACE and major bleeding at 1year.
研究表明，与经股动脉介入治疗（TFI）相比，经桡动脉介入治疗（TRI）可减少大出血，且与使用比伐卢定相比，使用肝素+糖蛋白IIb/IIIa抑制剂（GPI）时大出血也会减少。我们比较了退伍军人PCI时主要出血、死亡率以及动脉入路部位与所用抗凝剂之间的相互作用。
对2006年至2012年期间在一家退伍军人医院接受PCI的1192例连续患者的回顾性队列进行研究，将其分为TFI-肝素组（n = 192）、TFI-比伐卢定组（n = 272）、TRI-肝素组（n = 274）和TRI-比伐卢定组（n = 454）。主要结局为住院期间大出血、住院期间及1年全因死亡率。次要结局为住院期间心肌梗死、住院期间及1年主要不良心血管事件（MACE）和净不良心血管事件（NACE - 大出血+MACE的复合事件）。
与桡动脉入路相比，股动脉入路与大出血风险显著增加相关（OR 11.87，p<0.001）。相应地，与股动脉入路相比，桡动脉入路可预防大出血（OR 0.128，p<0.01），但本身并不能降低死亡率或MACE。严重贫血是住院期间全因死亡率的唯一预测因素（OR = 27.62，p<0.008）。贫血和年龄>70岁可预测1年死亡率，而大出血和贫血可预测1年MACE。在抗凝剂与入路部位之间发现了一种相互作用，即与桡动脉组相比，肝素在股动脉组中导致的大出血显著更多。无论入路部位如何，比伐卢定导致出血的风险相似。在降低1年NACE方面，桡动脉入路与肝素之间存在协同相互作用（HR 0.38，p<0.05），但桡动脉入路与比伐卢定之间不存在协同相互作用。
PCI采用桡动脉入路与大出血减少相关，但对住院期间或1年的MACE及死亡率无影响。大出血与短期和中期不良结局相关。此外，贫血与住院期间及1年死亡率增加密切相关。肝素对比伐卢定在大出血方面有不同影响，这取决于入路部位。桡动脉入路与比伐卢定在降低1年MACE和大出血的复合结局方面不存在协同作用。
