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目的了解置入药物洗脱支架(DES)患者术后的氯吡格雷治疗状况,探讨不同的疗程对晚期支架血栓(ST)发生的影响。方法连续入选2003年7月1日至2005年6月30日期间接受PCI并置入DES,且术后30天存活的患者,根据术后氯吡格雷的疗程将患者分为4组,即组1(<3月)、组2(3～6月)、组3(6～12月)和组4(>12月)。记录所入选患者住院期和随访期内临床资料,并根据ARCDublin定义判定ST事件。结果共2704例患者符合研究条件入选本研究。与组4患者相比,组1、组2的患者中合并糖尿病者较多,平均左室射血分数(LVEF)值较低,而ST段抬高型心肌梗死(STEMI)者较少,冠状动脉病变在各组之间无显著差异,但所置入DES数目较少。组1中断氯吡格雷治疗的患者中,自行停药比例较高;而组3中断氯吡格雷治疗的患者中,因医嘱停药的比例较高。多因素回归分析显示,影响患者提前中断氯吡格雷治疗的因素为:合并糖尿病(OR=1.542,95%CI1.184～2.008,P=0.001)和所置入DES的数目(OR=0.790,95%CI0.709～0.880,P<0.001)。晚期和晚晚期ST发生率在4组患者间差异有统计学意义(6.1%比1.2%比0.8%比0%,P<0.001),其中组3的ST发生率也较组4升高(0.8%比0%,P=0.013)。结论在临床实践中,有近3/4的患者在DES置入后的氯吡格雷疗程不足12个月。合并糖尿病和置入DES的数目是氯吡格雷疗程的独立影响因素。晚期和晚晚期ST的风险随氯吡格雷疗程的延长而降低。
Objective To investigate the therapeutic effect of clopidogrel after DES implantation in patients with advanced stent thrombosis (ST). Methods Patients were enrolled in this study. Patients who underwent PCI from January 1, 2003 to June 30, 2005 and survived at 30 days after surgery were divided into 4 groups according to the course of postoperative clopidogrel treatment: group 1 ( December). The clinical data of the selected patients during the hospitalization and follow-up were recorded and ST events were judged according to ARCDublin definition. Results A total of 2704 patients were eligible for the study. Compared with patients in group 4, patients in group 1 and group 2 had more diabetes, lower average LVEF, and less ST-segment elevation myocardial infarction (STEMI). Coronary Arterial lesions did not differ significantly among groups, but fewer DES were placed. Patients in group 1 who discontinued clopidogrel had a higher rate of discontinuation on their own, whereas patients in group 3 who discontinued clopidogrel had a higher rate of discontinuation due to doctor’s advice. Multivariate regression analysis showed that the factors influencing patients to discontinue clopidogrel prematurely were as follows: the number of patients with diabetes (OR = 1.542, 95% CI, 1.84-2.008, P = 0.001) % CI0.709 ~ 0.880, P <0.001). The incidence of ST in late stage and late stage was significantly different among the 4 groups (6.1% vs 1.2% vs 0.8% vs 0%, P <0.001), and the ST incidence of group 3 was also higher than that of group 4 % Vs 0%, P = 0.013). Conclusions In clinical practice, nearly three quarters of patients treated with clopidogrel after DES had been treated for less than 12 months. The number of patients with diabetes mellitus and DES placement is an independent contributor to the clopidogrel regimen. The risk of advanced and late stage ST decreases with prolonged use of clopidogrel.