高凝状态和纤溶功能障碍在急性心肌梗死中的预后影响
Prognostic impact of hypercoagulability and impaired fibrinolysis in acute myocardial infarction.
作者信息
Lee Seung Hun, Kim Hyun Kuk, Ahn Jong-Hwa, Kang Min Gyu, Kim Kye-Hwan, Bae Jae Seok, Cho Sang Young, Koh Jin-Sin, Park Yongwhi, Hwang Seok Jae, Gorog Diana A, Tantry Udaya S, Bliden Kevin P, Gurbel Paul A, Hwang Jin-Yong, Jeong Young-Hoon
机构信息
Division of Cardiology, Department of Internal Medicine, Heart Center, Chonnam National University Hospital, Chonnam National University Medical School, 42 Jebong-ro, Dong-gu, Gwangju, 61469, Republic of Korea.
Department of Internal Medicine and Cardiovascular Center, Chosun University Hospital, University of Chosun College of Medicine, 365, Pilmun-daero, Dong-gu, Gwangju, 61453, Republic of Korea.
出版信息
Eur Heart J. 2023 May 14;44(19):1718-1728. doi: 10.1093/eurheartj/ehad088.
AIMS
Atherothrombotic events are influenced by systemic hypercoagulability and fibrinolytic activity. The present study evaluated thrombogenicity indices and their prognostic implications according to disease acuity.
METHODS AND RESULTS
From the consecutive patients undergoing percutaneous coronary intervention (PCI), those with thrombogenicity indices (n = 2705) were grouped according to disease acuity [acute myocardial infarction (AMI) vs. non-AMI]. Thrombogenicity indices were measured by thromboelastography (TEG). Blood samples for TEG were obtained immediately after insertion of the PCI sheath, and TEG tracing was performed within 4 h post-sampling. Major adverse cardiovascular events (MACE, a composite of cardiovascular death, non-fatal myocardial infarction, and non-fatal stroke) were evaluated for up to 4 years. Compared with non-AMI patients, AMI patients had higher platelet-fibrin clot strength [maximal amplitude (MA): 66.5 ± 7.8 vs. 65.3 ± 7.2 mm, P < 0.001] and lower fibrinolytic activity [clot lysis at 30 min (LY30): 0.9 ± 1.8% vs. 1.1 ± 1.9%, P < 0.001]. Index AMI presentation was associated with MA [per one-mm increase: odds ratio (OR): 1.024; 95% confidence interval (CI): 1.013-1.036; P < 0.001] and LY30 (per one% increase: OR: 0.934; 95% CI: 0.893-0.978; P = 0.004). The presence of high platelet-fibrin clot strength (MA ≥68 mm) and low fibrinolytic activity (LY30 < 0.2%) was synergistically associated with MACE occurrence. In the multivariable analysis, the combined phenotype of 'MA ≥ 68 mm' and 'LY30 < 0.2%' was a major predictor of post-PCI MACE in the AMI group [adjusted hazard ratio (HR): 1.744; 95% CI: 1.135-2.679; P = 0.011], but not in the non-AMI group (adjusted HR: 1.031; 95% CI: 0.499-2.129; P = 0.935).
CONCLUSION
AMI occurrence is significantly associated with hypercoagulability and impaired fibrinolysis. Their combined phenotype increases the risk of post-PCI atherothrombotic event only in AMI patients. These observations may support individualized therapy that targets thrombogenicity for better outcomes in patients with AMI.
CLINICAL TRIAL REGISTRATION
Gyeongsang National University Hospital (G-NUH) Registry, NCT04650529.
目的
动脉粥样硬化血栓形成事件受全身高凝状态和纤溶活性影响。本研究根据疾病严重程度评估血栓形成指标及其预后意义。
方法与结果
在接受经皮冠状动脉介入治疗（PCI）的连续患者中，将具有血栓形成指标的患者（n = 2705）根据疾病严重程度[急性心肌梗死（AMI）与非AMI]分组。通过血栓弹力图（TEG）测量血栓形成指标。在插入PCI鞘管后立即采集用于TEG的血样，并在采样后4小时内进行TEG描记。评估长达4年的主要不良心血管事件（MACE，包括心血管死亡、非致命性心肌梗死和非致命性中风的复合事件）。与非AMI患者相比，AMI患者具有更高的血小板 - 纤维蛋白凝块强度[最大振幅（MA）：66.5±7.8 vs. 65.3±7.2 mm，P < 0.001]和更低的纤溶活性[30分钟时的凝块溶解（LY30）：0.9±1.8% vs. 1.1±1.9%，P < 0.001]。AMI表现与MA[每增加1毫米：比值比（OR）：1.024；95%置信区间（CI）：1.013 - 1.036；P < 0.001]和LY30（每增加1%：OR：0.934；95% CI：0.893 - 0.978；P = 0.004）相关。高血小板 - 纤维蛋白凝块强度（MA≥68 mm）和低纤溶活性（LY30 < 0.2%）的存在与MACE发生协同相关。在多变量分析中，“MA≥68 mm”和“LY30 < 0.2%”的联合表型是AMI组PCI术后MACE的主要预测指标[调整后风险比（HR）：1.744；95% CI：1.135 - 2.679；P = 0.011]，但在非AMI组中不是（调整后HR：1.031；95% CI：0.499 - 2.129；P = 0.935）。
结论
AMI的发生与高凝状态和纤溶功能受损显著相关。它们的联合表型仅在AMI患者中增加PCI术后动脉粥样硬化血栓形成事件的风险。这些观察结果可能支持针对血栓形成进行个体化治疗，以改善AMI患者的预后。
临床试验注册
庆尚国立大学医院（G - NUH）注册库，NCT04650529。
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