Université de Strasbourg, Pôle d'Activité Médico-Chirurgicale Cardio-Vasculaire, Nouvel Hôpital Civil, Centre Hospitalier Universitaire, Strasbourg, France; UMR1260 INSERM, Nanomédecine Régénérative, Faculté de Pharmacie, Université de Strasbourg, Illkirch, France.
Université de Strasbourg, Pôle d'Activité Médico-Chirurgicale Cardio-Vasculaire, Nouvel Hôpital Civil, Centre Hospitalier Universitaire, Strasbourg, France.
Int J Cardiol. 2022 Aug 1;360:53-61. doi: 10.1016/j.ijcard.2022.04.088. Epub 2022 May 4.
Dual antiplatelet therapy (DAPT) has been proposed to explain the increased occurrence of bleeding events after transcatheter aortic valve replacement (TAVR) despite no relevant study exploring the extent of platelet inhibition. In the present study, we sought to assess whether P2Y inhibition by clopidogrel impacts clinical outcomes in TAVR patients.
Patients were enrolled in a prospective registry at Nouvel Hôpital Civil, Strasbourg, France between February 2010 and May 2019. Vasodilator-stimulated phosphoprotein (VASP) flow cytometry test was assessed 24 h after the procedure. Responder to clopidogrel was defined by a platelet reactivity index ≤50%. The primary endpoint was 90-day major adverse cardiac and cerebrovascular events (MACCE), including all-cause death, myocardial infarction, stroke, and heart failure hospitalization.
Of the 828 patients with available VASP monitoring, 491 TAVR patients received preprocedural clopidogrel therapy. Responders were identified in 22% (n = 110) and low responders in 78% (n = 381) of patients. By multivariate Cox regression analysis, responders to clopidogrel (hazard ratio [HR]: 2.09; 95% confidence interval [CI]: 1.13 to 3.79: p = 0.02) and previous PCI (HR: 2.16; 95% CI: 1.02 to 4.68; p = 0.04) were identified as independent predictors of 90-day MACCE. The cumulative event-free survival rate at 90-day was significantly lower in the responder group (p = 0.008; log rank test).
In conclusion, appropriate P2Y inhibition by clopidogrel is a major determinant of MACCE at 90 days after TAVR. The present data challenge DAPT as a standard therapy during TAVR.
尽管没有相关研究探讨血小板抑制的程度，但经导管主动脉瓣置换术（TAVR）后出血事件发生率增加，提出了双联抗血小板治疗（DAPT）。本研究旨在评估氯吡格雷对 TAVR 患者临床结局的影响。
患者于 2010 年 2 月至 2019 年 5 月在法国斯特拉斯堡新民事医院前瞻性注册。术后 24 小时行血管扩张刺激磷蛋白（VASP）流式细胞术检测。以血小板反应指数≤50%定义氯吡格雷反应者。主要终点为 90 天主要不良心脑血管事件（MACCE），包括全因死亡、心肌梗死、卒中和心力衰竭住院。
在 828 例可进行 VASP 监测的患者中，491 例行 TAVR 患者接受了术前氯吡格雷治疗。22%（n=110）的患者为氯吡格雷反应者，78%（n=381）的患者为低反应者。多变量 Cox 回归分析显示，氯吡格雷反应者（风险比[HR]：2.09；95%置信区间[CI]：1.13 至 3.79；p=0.02）和既往 PCI（HR：2.16；95% CI：1.02 至 4.68；p=0.04）是 90 天 MACCE 的独立预测因素。90 天无事件生存率在反应者组明显较低（p=0.008；log rank 检验）。
氯吡格雷适当抑制 P2Y 是 TAVR 后 90 天 MACCE 的主要决定因素。本研究数据对 TAVR 期间 DAPT 作为标准治疗提出了挑战。
