Yudi Matias B, Farouque Omar, Andrianopoulos Nick, Ajani Andrew E, Brennan Angela, Lefkovits Jeffrey, Reid Christopher M, Chan William, Duffy Stephen J, Clark David J
Department of Cardiology, Austin Health, Melbourne, Australia.
Department of Medicine, University of Melbourne, Melbourne, Australia.
Catheter Cardiovasc Interv. 2018 Aug 1;92(2):E98-E105. doi: 10.1002/ccd.27325. Epub 2017 Sep 30.
The optimal time to administer P2Y inhibitors in patients with ST-elevation myocardial infarction (STEMI) remains to be defined. We sought to assess whether a pretreatment strategy was associated with improved coronary reperfusion and clinical outcomes.
Consecutive patients from the Melbourne Interventional Group registry (2005-2014) who presented with STEMI and underwent primary PCI were included. Those who received any P2Y inhibitor prior to arrival in the cardiac catheterisation laboratory were included in the pretreatment group. The primary endpoints were the proportion of patients with initial TIMI flow grade <3 and in-hospital bleeding. The secondary endpoints were 12-month mortality and major adverse cardiovascular events (MACE).
Of the 2,807 patients included, 892(31.8%) received pretreatment. Clopidogrel was the most common P2Y inhibitor used (79.6%). Pretreatment was associated with less thromboaspiration and GPIIb/IIIa inhibitor use (both P < 0.01). Pretreatment was not associated with lower rates of TIMI flow <3 on initial angiogram (78.0% vs. 80.7%, P = 0.18) nor with increased in-hospital bleeding (3.6% vs. 3.9%, P = 0.67). Pretreatment was associated with lower 12-month mortality (4.7% vs. 7.0%, P = 0.02) but similar MACE rate (13.0% vs. 14.1%, P = 0.43). Multivariate analysis revealed pretreatment was not an independent predictor of 12-month mortality (OR 0.79; 95% CI 0.5-1.3, P = 0.32).
Pretreatment with a P2Y inhibitor in patients with STEMI was not routine practice in our Australian cohort and was not associated with improved coronary reperfusion or clinical outcomes. Larger studies are required to definitively ascertain the risk/benefit ratio of dual antiplatelet therapy pretreatment in STEMI.
ST段抬高型心肌梗死（STEMI）患者使用P2Y抑制剂的最佳时间仍有待确定。我们试图评估预处理策略是否与改善冠状动脉再灌注及临床结局相关。
纳入墨尔本介入治疗组登记处（2005 - 2014年）中连续出现STEMI并接受直接经皮冠状动脉介入治疗（PCI）的患者。那些在到达心导管实验室之前接受过任何P2Y抑制剂治疗的患者被纳入预处理组。主要终点是初始心肌梗死溶栓治疗（TIMI）血流分级<3的患者比例和住院期间出血情况。次要终点是12个月死亡率和主要不良心血管事件（MACE）。
在纳入的2807例患者中，892例（31.8%）接受了预处理。氯吡格雷是最常用的P2Y抑制剂（79.6%）。预处理与较少的血栓抽吸和糖蛋白IIb/IIIa抑制剂使用相关（均P < 0.01）。预处理与初始血管造影时TIMI血流<3的发生率较低无关（78.0%对80.7%，P = 0.18），也与住院期间出血增加无关（3.6%对3.9%，P = 0.67）。预处理与较低的12个月死亡率相关（4.7%对7.0%，P = 0.02），但MACE发生率相似（13.0%对14.1%，P = 0.43）。多变量分析显示预处理不是12个月死亡率的独立预测因素（比值比0.79；95%置信区间0.5 - 1.3，P = 0.32）。
在我们的澳大利亚队列中，STEMI患者使用P2Y抑制剂进行预处理并非常规做法，且与改善冠状动脉再灌注或临床结局无关。需要更大规模的研究来明确确定STEMI中双重抗血小板治疗预处理的风险/效益比。
