University of Ottawa Heart Institute Ottawa Ontario Canada.
Gold Coast University Hospital Queensland Australia.
J Am Heart Assoc. 2021 Feb;10(5):e016602. doi: 10.1161/JAHA.120.016602. Epub 2021 Feb 18.
Background The optimal antiplatelet strategy for patients with acute coronary syndromes who require coronary artery bypass surgery remains unclear. While a more potent antiplatelet regimen will predispose to perioperative bleeding, it is hypothesized that through "platelet quiescence," ischemic protection conferred by such therapy may provide a net clinical benefit. Methods and Results We compared patients undergoing coronary artery bypass surgery who were treated with a more potent antiplatelet inhibition strategy with those with a less potent inhibition through a meta-analysis. The primary outcome was all-cause mortality after bypass surgery. The analysis identified 4 studies in which the antiplatelet regimen was randomized and 6 studies that were nonrandomized. Combining all studies, there was an overall higher mortality with weaker strategies compared with more potent strategies (odds ratio, 1.38; 95% CI, 1.03-1.85; =0.03). Conclusions Our findings support the concept of platelet quiescence, in reducing mortality for patients with acute coronary syndrome requiring coronary artery bypass surgery. This suggests the routine up-front use of potent antiplatelet regimens in acute coronary syndrome, irrespective of likelihood of coronary artery bypass graft.
对于需要冠状动脉旁路移植术的急性冠脉综合征患者，最佳的抗血小板策略仍不明确。虽然更强效的抗血小板方案会增加围手术期出血的风险，但有假设认为，通过“血小板静止”，这种治疗所带来的缺血保护可能会提供净临床获益。
我们通过荟萃分析比较了接受冠状动脉旁路移植术的患者，他们接受的是更强效的抗血小板抑制策略与那些接受较弱抑制策略的患者。主要结局是旁路手术后的全因死亡率。分析确定了 4 项随机抗血小板方案的研究和 6 项非随机研究。综合所有研究，与更强效的策略相比，较弱的策略总体上导致更高的死亡率（比值比，1.38；95%置信区间，1.03-1.85；=0.03）。
我们的发现支持血小板静止的概念，即减少需要冠状动脉旁路移植术的急性冠脉综合征患者的死亡率。这表明，无论是否可能进行冠状动脉旁路移植术，急性冠脉综合征患者都应常规使用强效的抗血小板方案。
