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BMJ:长期双联抗血小板治疗对于冠脉支架置入患者有益吗?

2016-11-04 xing.T MedSci原创

虽然糖尿病是患者植入药物洗脱支架后MACE的独立预测因子,但是相比于短期DAPT,长期DAPT并没有减少MACE风险,反而增加植入支架患者的出血风险,无论其有无合并糖尿病。

双联抗血小板治疗(DAPT)是接受经皮冠状动脉介入治疗患者的标准治疗方案,其治疗意义在于减少冠状动脉支架植入术后支架内血栓形成的风险,并预防支架以外的冠状动脉粥样硬化的发生。然而,植入普通支架的患者术后DAPT的最佳持续时间,尤其是对于植入药物洗脱支架的患者,仍然存在争议。而且,糖尿病是当今公认的动脉粥样硬化、疾病进展和经皮冠状动脉介入术后再狭窄的危险因素。最近,顶级杂志BMJ上发表了一篇来自瑞士伯尔尼大学附属医院心内科Giuseppe Gargiulo医生及其团队的研究文章,旨在比较有/无糖尿病患者在植入药物洗脱支架后短期(6个月)和长期(12个月)DAPT的临床预后。

研究者将参与者数据进行荟萃分析,采用Cox回归模型评估糖尿病对临床预后的影响。研究者检索了MEDLINE、EMBASE、Cochrane数据库和国际会议文献,主要搜索比较药物洗脱支架植入术后DAPT时程对患者预后的随机对照试验。

研究的主要预后指标是一年后心脏主要不良事件(MACE)的风险,MACE是指发生心源性死亡、心肌梗死或明确/很大可能的支架内血栓。


研究者共纳入六个随机对照试验,包括11,473例患者,这些患者中,有3681(32.1%)例糖尿病患者和7708(67.2%)例非糖尿病患者[平均年龄分别为63.7(标准差为9.9)和62.8(标准差为10.1)],另有84(0.7%)例患者随访信息丢失。

糖尿病是MACE的独立预测因子(危险比为2.30,95%置信区间为1.01-5.27;P=0.048),相对于短期DAPT患者(危险比为1.05,95%置信区间为0.62-1.76;P=0.86)或非糖尿病患者(危险比为0.97,95%置信区间为0.67-1.39;P=0.85),长期DAPT与降低的MACE风险并不相关(P交互作用=0.33)。

心肌梗死的风险在两种不同时程的DAPT组之间也不存在差异(在糖尿病患者中危险比为0.95,95%置信区间为0.58-1.54;P=0.82;对于非糖尿病患者危险比为1.15,95%置信区间为0.68-1.94;P=0.60;P交互作用=0.84)。

研究者发现相对于接受长期DAPT的非糖尿病患者(危险比为1.42,95%置信区间为0.68-2.98;P=0.35),接受长期DAPT的糖尿病患者发生确定/很大可能的支架内血栓的风险较低(危险比为0.26,95%置信区间为0.09-0.80;P = 0.02),并且交互作用有统计学意义(P交互作用=0.04),虽然这两组分析结果具有统计学意义,并显示出能够获得临床效益,但不管是否患有糖尿病,长期DAPT与严重或轻微出血高发生率相关(P交互作用=0.37)。

综上所述,虽然糖尿病是患者植入药物洗脱支架后MACE的独立预测因子,但是相比于短期DAPT,长期DAPT并没有减少MACE风险,反而增加植入支架患者的出血风险,无论患者是否合并糖尿病。

原始出处:

Giuseppe Gargiulo,et al. Short term versus long term dual antiplatelet therapy after implantation of drug eluting stent in patients with or without diabetes: systematic review and meta-analysis of individual participant data from randomised trials. BMJ
03 November 2016.  http://dx.doi.org/10.1136/bmj.i5483

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