Department of Cardiology, Sahlgrenska University Hospital, Bruna stråket 16, Gothenburg, Sweden.
Department of Cardiology, Danderyd University Hospital, Stockholm, Sweden.
Eur Heart J. 2019 Apr 14;40(15):1202-1210. doi: 10.1093/eurheartj/ehz069.
Pretreatment of patients with ST-elevation myocardial infarction (STEMI) with P2Y12 receptor antagonists is supported by guidelines and is a common practice despite the lack of definite evidence for its benefit.
Using data from the Swedish Coronary Angiography and Angioplasty Registry on procedures between 2005 and 2016, we stratified all patients who underwent primary percutaneous coronary intervention due to STEMI in Sweden by whether or not they were pretreated with P2Y12 receptor antagonists. We investigated associations between pretreatment with P2Y12 receptor antagonists and the risk of adverse outcomes using propensity score-adjusted mixed-effects logistic regression, which accounted for clustering of patients within hospitals. The primary endpoint was all-cause death within 30 days. Secondary endpoints were infarct-related artery (IRA) occlusion, 30-day stent thrombosis, in-hospital bleeding, neurological complications, and cardiogenic shock. In total, 44 804 patients were included. They were treated with clopidogrel (N = 26 136, 58.3%), ticagrelor (N = 15 792, 35.3%), or prasugrel (N = 2352, 5.3%); 37 840 (84.5%) were pretreated, and 30 387 (67.8%) had IRA occlusion. At 30 days, there were 2488 (5.6%) deaths and 267 (0.6%) stent thrombosis. Pretreatment was not associated with better survival at 30 days [odds ratio (OR) 1.08, 95% confidence interval (CI) 0.95-1.24; P = 0.313], reduced IRA occlusion (OR 0.98, 95% CI 0.92-1.05; P = 0.608), decreased stent thrombosis (OR 0.99, 95% CI 0.69-1.43; P = 0.932), higher risk of in-hospital bleeding (OR 1.05, 95% CI 0.89-1.26; P = 0.526), or neurological complications (OR 0.72, 95% CI 0.43-1.21; P = 0.210).
Pretreatment of STEMI patients with P2Y12 receptor antagonists was not associated with improved clinical outcomes.
尽管缺乏明确的获益证据，指南仍推荐对 ST 段抬高型心肌梗死（STEMI）患者进行 P2Y12 受体拮抗剂预处理，这已成为一种常规做法。
利用瑞典冠状动脉血管造影和血管成形术注册中心 2005 年至 2016 年期间的程序数据，我们根据瑞典所有因 STEMI 而行直接经皮冠状动脉介入治疗的患者是否接受 P2Y12 受体拮抗剂预处理进行分层。我们使用倾向评分调整混合效应逻辑回归来研究 P2Y12 受体拮抗剂预处理与不良结局风险之间的关联，该回归考虑了患者在医院内的聚类。主要终点为 30 天内全因死亡。次要终点包括梗死相关动脉（IRA）闭塞、30 天内支架血栓形成、住院期间出血、神经并发症和心源性休克。共纳入 44804 例患者。其中，接受氯吡格雷（N=26136，58.3%）、替格瑞洛（N=15792，35.3%）或普拉格雷（N=2352，5.3%）治疗；37840 例（84.5%）接受预处理，30387 例（67.8%）IRA 闭塞。30 天时，有 2488 例（5.6%）死亡和 267 例（0.6%）支架血栓形成。预处理与 30 天生存率的改善无关[比值比（OR）1.08，95%置信区间（CI）0.95-1.24；P=0.313]、IRA 闭塞减少（OR 0.98，95%CI 0.92-1.05；P=0.608）、支架血栓形成减少（OR 0.99，95%CI 0.69-1.43；P=0.932）、住院期间出血风险增加（OR 1.05，95%CI 0.89-1.26；P=0.526）或神经并发症（OR 0.72，95%CI 0.43-1.21；P=0.210）。
STEMI 患者接受 P2Y12 受体拮抗剂预处理与临床结局改善无关。
