前瞻性观察性队列研究抗血小板治疗与冠状动脉支架置入术后非心脏手术患者出血和血栓形成的关系。
Prospective observational cohort study of the association between antiplatelet therapy, bleeding and thrombosis in patients with coronary stents undergoing noncardiac surgery.
机构信息
Leeds Institute of Medical Research at St James's, University of Leeds, Leeds, UK.
Department of Anaesthesiology, Erasmus University Medical Centre, Rotterdam, the Netherlands.
出版信息
Br J Anaesth. 2019 Feb;122(2):170-179. doi: 10.1016/j.bja.2018.09.029. Epub 2018 Dec 15.
BACKGROUND
The perioperative management of antiplatelet therapy in noncardiac surgery patients who have undergone previous percutaneous coronary intervention (PCI) remains a dilemma. Continuing dual antiplatelet therapy (DAPT) may carry a risk of bleeding, while stopping antiplatelet therapy may increase the risk of perioperative major adverse cardiovascular events (MACE).
METHODS
Occurrence of Bleeding and Thrombosis during Antiplatelet Therapy In Non-Cardiac Surgery (OBTAIN) was an international prospective multicentre cohort study of perioperative antiplatelet treatment, MACE, and serious bleeding in noncardiac surgery. The incidences of MACE and bleeding were compared in patients receiving DAPT, monotherapy, and no antiplatelet therapy before surgery. Unadjusted risk ratios were calculated taking monotherapy as the baseline. The adjusted risks of bleeding and MACE were compared in patients receiving monotherapy and DAPT using propensity score matching.
RESULTS
A total of 917 patients were recruited and 847 were eligible for inclusion. Ninety-six patients received no antiplatelet therapy, 526 received monotherapy with aspirin, and 225 received DAPT. Thirty-two patients suffered MACE and 22 had bleeding. The unadjusted risk ratio for MACE in patients receiving DAPT compared with monotherapy was 1.9 (0.93-3.88), P=0.08. There was no difference in MACE between no antiplatelet treatment and monotherapy 1.03 (0.31-3.46), P=0.96. Bleeding was more frequent with DAPT 6.55 (2.3-17.96) P=0.0002. In a propensity matched analysis of 177 patients who received DAPT and 177 monotherapy patients, the risk ratio for MACE with DAPT was 1.83 (0.69-4.85), P=0.32. The risk of bleeding was significantly greater in the DAPT group 4.00 (1.15-13.93), P=0.031.
CONCLUSIONS
OBTAIN showed an increased risk of bleeding with DAPT and found no evidence for protective effects of DAPT from perioperative MACE in patients who have undergone previous PCI.
背景
在接受过经皮冠状动脉介入治疗 (PCI) 的非心脏手术患者中，抗血小板治疗的围手术期管理仍然是一个难题。继续双联抗血小板治疗 (DAPT) 可能有出血风险，而停止抗血小板治疗可能会增加围手术期主要不良心血管事件 (MACE) 的风险。
方法
非心脏手术期间抗血小板治疗致出血和血栓形成（OBTAIN）是一项国际性的前瞻性多中心队列研究，研究了围手术期抗血小板治疗、MACE 和非心脏手术中的严重出血。比较了术前接受 DAPT、单药治疗和无抗血小板治疗的患者的 MACE 和出血发生率。以单药治疗为基线计算未调整的风险比。使用倾向评分匹配比较接受单药治疗和 DAPT 的患者的出血和 MACE 调整风险。
结果
共招募了 917 名患者，其中 847 名符合入选标准。96 名患者未接受抗血小板治疗，526 名患者接受阿司匹林单药治疗，225 名患者接受 DAPT。32 名患者发生 MACE，22 名患者发生出血。与单药治疗相比，接受 DAPT 的患者发生 MACE 的未调整风险比为 1.9（0.93-3.88），P=0.08。无抗血小板治疗与单药治疗相比，MACE 无差异 1.03（0.31-3.46），P=0.96。DAPT 出血更频繁 6.55（2.3-17.96），P=0.0002。在对接受 DAPT 和 177 名单药治疗的患者进行的 177 例倾向匹配分析中，DAPT 的 MACE 风险比为 1.83（0.69-4.85），P=0.32。DAPT 组出血风险显著增加 4.00（1.15-13.93），P=0.031。
结论
OBTAIN 显示 DAPT 出血风险增加，并且在接受过 PCI 的患者中没有发现 DAPT 对围手术期 MACE 的保护作用。
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