TIMI Study Group, Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.
TIMI Study Group, Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.
J Am Coll Cardiol. 2020 Mar 17;75(10):1095-1106. doi: 10.1016/j.jacc.2019.12.067.
Recent emphasis on reduced duration and/or intensity of antiplatelet therapy following percutaneous coronary intervention (PCI) irrespective of indication for PCI may fail to account for the substantial risk of subsequent nontarget lesion events in acute coronary syndrome (ACS) patients.
The authors sought to examine the effect of more potent antiplatelet therapy on the basis of the timing and etiology of recurrent myocardial infarction (MI) or cardiovascular death following PCI for ACS.
In the TRITON-TIMI 38 study (Trial to Assess Improvement in Therapeutic Outcomes by Optimizing Platelet Inhibition With Prasugrel-Thrombolysis In Myocardial Infarction 38), which randomized patients to prasugrel or clopidogrel, 12,844 patients with ACS received at least 1 stent. MI and cardiovascular death were categorized as: 1) procedural (related to revascularization); 2) definite or probable stent thrombosis (ST); or 3) spontaneous (non-ST or non-procedure-related). Median follow-up was 14.5 months.
Among the first events occurring within 30 days, 584 (69.0%) were procedural, 126 (14.9%) ST-related, and 136 (16.1%) spontaneous. After 30 days, 22 (4.7%) were procedural, 63 (13.5%) were ST-related, and 383 (81.8%) spontaneous. Prasugrel significantly reduced the incidence of MI or cardiovascular death for ST-related (1.0% vs. 2.1%; p < 0.001) and spontaneous events (3.9% vs. 4.8%; p = 0.012), with a directionally consistent numerical reduction for procedural events (4.4% vs. 5.1%; p = 0.078). Prasugrel increased spontaneous, but not procedural, major bleeding.
Long-term potent antithrombotic therapy reduces de novo (spontaneous) atherothrombotic events in addition to preventing complications associated with stenting of the culprit lesion following ACS. In patients undergoing PCI for ACS, spontaneous events predominate after 30 days, with the later-phase cardiovascular benefit of potent dual antiplatelet therapy driven largely by reducing de novo atherothrombotic ischemic events. (Comparison of Prasugrel [CS-747] and Clopidogrel in Acute Coronary Syndrome Subjects Who Are to Undergo Percutaneous Coronary Intervention; NCT00097591).
近期，经皮冠状动脉介入治疗（PCI）后抗血小板治疗的持续时间和/或强度有所降低，无论 PCI 的适应证如何，这可能无法充分考虑急性冠状动脉综合征（ACS）患者后续非靶病变事件的高风险。
作者试图根据 ACS 患者 PCI 后新发心肌梗死（MI）或心血管死亡的时间和病因，评估更有效的抗血小板治疗的效果。
在 TRITON-TIMI 38 研究（评估普拉格雷优化血小板抑制治疗改善治疗结局的试验-心肌梗死 38）中，患者被随机分配至普拉格雷或氯吡格雷组，12844 例 ACS 患者至少植入了 1 枚支架。MI 和心血管死亡被分为以下几类：1）手术相关（与血运重建相关）；2）明确或可能的支架血栓形成（ST）；3）自发性（非 ST 或非手术相关）。中位随访时间为 14.5 个月。
在 30 天内首次发生的事件中，584 例（69.0%）为手术相关，126 例（14.9%）为 ST 相关，136 例（16.1%）为自发性。30 天后，22 例（4.7%）为手术相关，63 例（13.5%）为 ST 相关，383 例（81.8%）为自发性。普拉格雷显著降低了 ST 相关（1.0% vs. 2.1%；p<0.001）和自发性事件（3.9% vs. 4.8%；p=0.012）的 MI 或心血管死亡发生率，手术相关事件（4.4% vs. 5.1%；p=0.078）也有降低趋势。普拉格雷增加了自发性但未增加手术相关的大出血。
长期强效抗血栓治疗除了预防 ACS 罪犯病变支架置入相关并发症外，还可减少新发生的（自发性）动脉粥样硬化血栓事件。在 ACS 患者接受 PCI 治疗后，30 天后自发性事件占主导地位，强效双联抗血小板治疗的后期心血管获益主要归因于减少新发生的动脉粥样硬化血栓性缺血事件。（普拉格雷[CS-747]与拟行经皮冠状动脉介入治疗的急性冠状动脉综合征患者的氯吡格雷比较；NCT00097591）。
