Flores-Blanco Pedro J, Cambronero-Sánchez Francisco, Raposeiras-Roubin Sergio, Abu-Assi Emad, Leithold Gunnar, Cobas-Paz Rafael, Rodríguez Serrano Ana I, Calvo-Iglesias Francisco, Valdés Mariano, Januzzi James L, Iñiguez-Romo Andrés, Manzano-Fernández Sergio
Departamento de Medicina Interna, Servicio de Cardiología, Hospital Clínico Universitario Virgen de la Arrixaca, Instituto Murciano de Investigación Biosanitaria, El Palmar, Murcia, Spain.
Departamento de Medicina Interna, Servicio de Cardiología, Hospital General Universitario Los Arcos del Mar Menor, San Javier, Murcia, Spain.
Rev Esp Cardiol (Engl Ed). 2018 Jul;71(7):538-544. doi: 10.1016/j.rec.2017.10.009. Epub 2017 Nov 14.
Acute coronary syndrome (ACS) guidelines recommend the use of newer P2Y inhibitors (prasugrel and ticagrelor) over clopidogrel in patients with moderate-to-high ischemic risk, unless they have an increased bleeding risk. The aim of our study was to assess the GRACE risk score and the CRUSADE bleeding risk score relative to prescription of newer P2Y inhibitors at discharge in ACS patients.
Retrospective analysis of a multicenter ACS registry; 3515 consecutive patients were included. The association between risk scores and prescription of newer P2Y inhibitors was assessed by binary logistic regression analysis.
A total of 1021 patients (29%) were treated with prasugrel or ticagrelor. On multivariate analyses, both GRACE (OR per 10 points, 0.89; 95%CI, 0.86-0.92; P < .001) and CRUSADE (OR per 10 points, 0.96; 95%CI, 0.94-0.98; P < .001) risk scores were inversely associated with the use of newer P2Y inhibitors. Moreover, other factors not included in these scores (revascularization approach, in-hospital stent thrombosis, major bleeding, and concomitant indication for anticoagulation therapy) also predicted the use of newer P2Y inhibitors.
New P2Y inhibitors were more frequently prescribed among ACS patients with lower CRUSADE bleeding risk. However, an ischemic risk paradox was found, with higher use of these agents in patients with lower ischemic risk based on GRACE risk score estimates. These results underscore the importance of risk stratification to safely deliver optimal therapies.
急性冠状动脉综合征（ACS）指南推荐，对于中高缺血风险患者，除非出血风险增加，应使用新型P2Y抑制剂（普拉格雷和替格瑞洛）而非氯吡格雷。我们研究的目的是评估ACS患者出院时与新型P2Y抑制剂处方相关的GRACE风险评分和CRUSADE出血风险评分。
对一个多中心ACS登记处进行回顾性分析；纳入3515例连续患者。通过二元逻辑回归分析评估风险评分与新型P2Y抑制剂处方之间的关联。
共有1021例患者（29%）接受了普拉格雷或替格瑞洛治疗。在多变量分析中，GRACE（每10分的比值比，0.89；95%置信区间，0.86 - 0.92；P <.001）和CRUSADE（每10分的比值比，0.96；95%置信区间，0.94 - 0.98；P <.001）风险评分均与新型P2Y抑制剂的使用呈负相关。此外，这些评分未包括的其他因素（血运重建方法、院内支架血栓形成、大出血以及抗凝治疗的伴随指征）也可预测新型P2Y抑制剂的使用。
在CRUSADE出血风险较低的ACS患者中，新型P2Y抑制剂的处方更为频繁。然而，发现了一个缺血风险悖论，即基于GRACE风险评分估计，这些药物在缺血风险较低的患者中使用频率更高。这些结果强调了风险分层对于安全提供最佳治疗的重要性。
