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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2017-03-28 smallant2010

#冠脉支架#

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2017-04-15 gaoxiaoe

#BMJ#

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2017-04-28 tulenzi

#双联抗血小板#

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2016-11-06 12498bf3m28暂无昵称

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