基于临床表现和血小板反应性的支架内血栓形成风险随时间变化：来自ADAPT-DES的分析
Stent Thrombosis Risk Over Time on the Basis of Clinical Presentation and Platelet Reactivity: Analysis From ADAPT-DES.
作者信息
Chau Katherine H, Kirtane Ajay J, Easterwood Rachel M, Redfors Björn, Zhang Zixuan, Witzenbichler Bernhard, Weisz Giora, Stuckey Thomas D, Brodie Bruce R, Rinaldi Michael J, Neumann Franz-Josef, Metzger D Christopher, Henry Timothy D, Cox David A, Duffy Peter L, Mazzaferri Ernest L, Mehran Roxana, Stone Gregg W
机构信息
Clinical Trials Center, Cardiovascular Research Foundation, New York, New York, USA; Herbert and Sandi Feinberg Interventional Cardiology and Heart Valve Center at Columbia University Irving Medical Center/NewYork-Presbyterian Hospital, New York, New York, USA.
Clinical Trials Center, Cardiovascular Research Foundation, New York, New York, USA; Herbert and Sandi Feinberg Interventional Cardiology and Heart Valve Center at Columbia University Irving Medical Center/NewYork-Presbyterian Hospital, New York, New York, USA.
出版信息
JACC Cardiovasc Interv. 2021 Feb 22;14(4):417-427. doi: 10.1016/j.jcin.2020.12.005. Epub 2021 Jan 27.
OBJECTIVES
The aim of this study was to determine the risk period for increased stent thrombosis (ST) after percutaneous coronary intervention (PCI) in patients with acute coronary syndromes (ACS) and whether this increased risk is related to high platelet reactivity (HPR).
BACKGROUND
ST risk after PCI is higher among patients with ACS than those with stable ischemic heart disease. When ST risk is highest in patients with ACS and how that is affected by HPR is unknown.
METHODS
Using the ADAPT-DES (Assessment of Dual Antiplatelet Therapy With Drug-Eluting Stents) registry, ST rates during 2-year follow-up post-PCI with drug-eluting stents were compared among patients presenting with ACS (myocardial infarction [MI] or unstable angina) or stable ischemic heart disease (non-ACS). Landmark analyses were done at 30 days and 1 year post-PCI. Platelet reactivity on aspirin and clopidogrel post-PCI was assessed using VerifyNow assays.
RESULTS
Of 8,582 patients, 2,063 presented with MI, 2,370 with unstable angina, and 4,149 with non-ACS. Incidence rates of HPR were 48.0%, 43.3%, and 39.8%, respectively (p < 0.001). Within the first 30 days post-PCI, patients presenting with MI had increased ST risk compared with patients with non-ACS (hazard ratio [HR]: 4.52; 95% confidence interval [CI]: 2.01 to 10.14; p < 0.001). After 30 days, relative ST risks were progressively lower and no longer significant between groups (31 days to 1 year post-PCI: HR: 1.97; 95% CI: 0.80 to 4.85; >1 year post-PCI: HR: 0.89; 95% CI: 0.27 to 2.92). The elevated ST risk in patients with MI within 30 days was largely confined to those with HPR on clopidogrel (HR: 5.77; 95% CI: 2.13 to 15.63; p < 0.001).
CONCLUSIONS
Among patients undergoing PCI, rates of ST during 2-year follow-up were highest in those with MI and lowest in those with non-ACS. Increased ST risk in patients with MI was greatest in the first 30 days post-PCI and was observed predominantly among those with increased HPR on clopidogrel. These findings emphasize the importance of adequate P2Y inhibition after MI, especially within the first 30 days after stent implantation.
目的
本研究旨在确定急性冠状动脉综合征（ACS）患者经皮冠状动脉介入治疗（PCI）后支架内血栓形成（ST）增加的风险期，以及这种增加的风险是否与高血小板反应性（HPR）有关。
背景
ACS患者PCI后的ST风险高于稳定型缺血性心脏病患者。ACS患者的ST风险何时最高以及HPR如何影响该风险尚不清楚。
方法
使用ADAPT-DES（药物洗脱支架双重抗血小板治疗评估）注册研究，比较接受药物洗脱支架PCI后2年随访期间ACS（心肌梗死[MI]或不稳定型心绞痛）或稳定型缺血性心脏病（非ACS）患者的ST发生率。在PCI后30天和1年进行标志性分析。使用VerifyNow检测评估PCI后阿司匹林和氯吡格雷的血小板反应性。
结果
在8582例患者中，2063例为MI，2370例为不稳定型心绞痛，4149例为非ACS。HPR发生率分别为48.0%、43.3%和39.8%（p<0.001）。在PCI后的前30天内，MI患者的ST风险高于非ACS患者（风险比[HR]：4.52；95%置信区间[CI]：2.01至10.14；p<0.001）。30天后，相对ST风险逐渐降低，两组之间不再显著（PCI后31天至1年：HR：1.97；95%CI：0.80至4.85；PCI后>1年：HR：0.89；95%CI：0.27至2.92）。MI患者在30天内升高的ST风险主要局限于氯吡格雷HPR患者（HR：5.77；95%CI：2.13至15.63；p<0.001）。
结论
在接受PCI的患者中，2年随访期间ST发生率在MI患者中最高，在非ACS患者中最低。MI患者ST风险增加在PCI后最初30天内最大，且主要在氯吡格雷HPR增加的患者中观察到。这些发现强调了MI后充分抑制P2Y的重要性，尤其是在支架植入后的前30天内。
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