Division of Cardiology, Duke University, Durham, NC
Duke Clinical Research Institute, Duke University, Durham, NC.
J Am Heart Assoc. 2018 Feb 8;7(4):e007982. doi: 10.1161/JAHA.117.007982.
Guidelines recommend P2Y inhibitor therapy for 1 year after myocardial infarction (MI), yet little guidance is provided on antiplatelet management for patients with recurrent ischemic events during that year. We describe changes in P2Y inhibitor type among patients with recurrent ischemic events in the first year after MI.
The TRANSLATE-ACS (Treatment With ADP Receptor Inhibitors: Longitudinal Assessment of Treatment Patterns and Events After Acute Coronary Syndrome) study enrolled 12 365 patients with MI treated with percutaneous coronary intervention. We examined whether P2Y inhibitor choice changed among patients with recurrent MI, stent thrombosis, and/or unplanned revascularization during the first year after MI, and modeled factors associated with P2Y inhibitor intensification (changing clopidogrel to prasugrel or ticagrelor). In the first year after MI, 1414 patients (11%) had a total of 1740 recurrent ischemic events (771 recurrent MIs, 969 unplanned revascularizations, and 165 stent thromboses). Median time to the first recurrent ischemic event was 154 days (25th-75th percentiles, 55-287 days). Of those with recurrent ischemic events, 101 of 1092 (9.3%) occurring in clopidogrel-treated patients led to P2Y inhibitor intensification. Recurrent events involving stent thrombosis or MI were the strongest factors associated with P2Y inhibitor intensification, yet only 40% of patients with stent thrombosis and 14% of patients with recurrent MI had P2Y inhibitor intensification. Increasing age and longer time from the index MI were associated with lower likelihood for intensification.
Few patients after MI with a recurrent ischemic event who were taking clopidogrel switched to a more potent P2Y inhibitor, even after stent thrombosis events. Specific guidance is needed for patients who have recurrent ischemic events, particularly when closely spaced.
URL: https://www.clinicaltrials.gov. Unique identifier: NCT01088503.
指南建议心肌梗死（MI）后使用 P2Y 抑制剂治疗 1 年，但对于 MI 后 1 年内发生复发性缺血事件患者的抗血小板管理，指南提供的指导很少。我们描述了 MI 后 1 年内发生复发性缺血事件患者的 P2Y 抑制剂类型的变化。
TRANSLATE-ACS（急性冠状动脉综合征治疗中 ADP 受体抑制剂：治疗模式和事件的纵向评估）研究纳入了 12365 例接受经皮冠状动脉介入治疗的 MI 患者。我们研究了 MI 后 1 年内发生复发性 MI、支架血栓形成和/或计划外血运重建的患者中 P2Y 抑制剂选择是否发生变化，并对与 P2Y 抑制剂强化相关的因素（将氯吡格雷改为普拉格雷或替格瑞洛）进行建模。在 MI 后 1 年内，1414 例（11%）患者共发生 1740 例复发性缺血事件（771 例复发性 MI、969 例计划外血运重建和 165 例支架血栓形成）。首次复发性缺血事件的中位时间为 154 天（25%75%分位数，55287 天）。在发生复发性缺血事件的患者中，在氯吡格雷治疗的患者中，有 101 例（9.3%）导致 P2Y 抑制剂强化。涉及支架血栓形成或 MI 的复发性事件是与 P2Y 抑制剂强化最密切相关的因素，但只有 40%的支架血栓形成患者和 14%的复发性 MI 患者进行了 P2Y 抑制剂强化。年龄增长和从 MI 到事件的时间延长与强化可能性降低相关。
MI 后发生复发性缺血事件且服用氯吡格雷的患者中，很少有患者改用更有效的 P2Y 抑制剂，即使发生支架血栓形成事件也是如此。对于发生复发性缺血事件的患者，尤其是在间隔时间较短的情况下，需要特定的指导。
