Ferlini Marco, Musumeci Giuseppe, Grieco Niccolò, Rossini Roberta, De Servi Stefano, Mafrici Antonio, Sponzilli Carlo, Demarchi Andrea, Assanelli Emilio M, Camisasca Paola, Chizzola Giuliano, Corrada Elena, Farina Andrea, Pedrinazzi Claudio, Lettieri Corrado, Oltrona Visconti Luigi
SC Cardiologia Fondazione IRCCS Policlinico San Matteo, Pavia.
SC Cardiologia, Ospedale Santa Croce e Carle, Cuneo.
Coron Artery Dis. 2018 Jun;29(4):309-315. doi: 10.1097/MCA.0000000000000601.
Patients with diabetes mellitus (DM) and acute coronary syndromes have a greater level of platelet aggregation and a poor response to oral antiplatelet drugs. Clopidogrel is still widely used in clinical practice, despite the current evidence favoring ticagrelor and prasugrel.
The aim of this study was to investigate the determinants of clopidogrel use in the population of the multicenter prospective 'Acute Coronary Syndrome and Diabetes Registry' carried out during a 9-week period between March and May 2015 at 29 Hospitals.
A total of 559 consecutive acute coronary syndrome patients [mean age: 68.7±11.3 years, 50% ST-elevation myocardial infarction (STEMI)], with 'known DM' (56%) or 'hyperglycemia' at admission, were included in the registry; 460 (85%) patients received a myocardial revascularization.
At hospital discharge, dual antiplatelet therapy was prescribed to 88% of the patients (clopidogrel ticagrelor and prasugrel to 39, 38, and 23%, respectively). Differences in P2Y12 inhibitor administration were recorded on the basis of history of diabetes, age, and clinical presentation (unstable angina/non-STEMI vs. non-STEMI). On univariate analysis, age older than 75 years or more, known DM, peripheral artery disease, previous myocardial infarction, previous revascularization, complete revascularization, previous cerebrovascular event, creatinine clearance, unstable angina/non-STEMI at presentation, Global Registry of Acute Coronary Events Score, EuroSCORE, CRUSADE Bleeding Score, and oral anticoagulant therapy were significantly associated with clopidogrel choice at discharge. On multivariate analysis, only oral anticoagulant therapy and the CRUSADE Bleeding Score remained independent predictors of clopidogrel prescription.
In the present registry of a high-risk population, clopidogrel was the most used P2Y12 inhibitor at hospital discharge, confirming the 'paradox' to treat sicker patients with the less effective drug. Diabetic status, a marker of higher thrombotic risk, did not influence this choice; however, bleeding risk was taken into account.
糖尿病（DM）合并急性冠脉综合征的患者血小板聚集水平更高，对口服抗血小板药物反应较差。尽管目前有证据支持替格瑞洛和普拉格雷，但氯吡格雷仍在临床实践中广泛使用。
本研究旨在调查在2015年3月至5月期间的9周内，于29家医院开展的多中心前瞻性“急性冠脉综合征与糖尿病登记研究”人群中使用氯吡格雷的决定因素。
共有559例连续性急性冠脉综合征患者[平均年龄：68.7±11.3岁，50%为ST段抬高型心肌梗死（STEMI）]纳入登记研究，这些患者入院时患有“已知糖尿病”（56%）或“高血糖”；460例（85%）患者接受了心肌血运重建术。
出院时，88%的患者接受了双联抗血小板治疗（分别有39%、38%和23%的患者接受氯吡格雷、替格瑞洛和普拉格雷治疗）。根据糖尿病病史、年龄和临床表现（不稳定型心绞痛/非STEMI与STEMI）记录了P2Y12抑制剂使用的差异。单因素分析显示，年龄大于75岁或更高、已知糖尿病、外周动脉疾病、既往心肌梗死、既往血运重建术、完全血运重建术、既往脑血管事件、肌酐清除率、入院时不稳定型心绞痛/非STEMI、急性冠脉事件全球登记评分、欧洲心脏手术风险评估系统评分、CRUSADE出血评分和口服抗凝治疗与出院时选择氯吡格雷显著相关。多因素分析显示，只有口服抗凝治疗和CRUSADE出血评分仍然是氯吡格雷处方的独立预测因素。
在本次高危人群登记研究中，氯吡格雷是出院时最常用的P2Y12抑制剂，证实了用疗效较差的药物治疗病情较重患者这一“矛盾”现象。糖尿病状态作为血栓形成风险较高的一个指标，并未影响这一选择；然而，出血风险是被考虑在内的。
