冠状动脉旁路移植术后患者血小板高反应性的影响因素分析

doi:10.3760/cma.j.issn.1007-1245.2022.02.025

摘要/Abstract

摘要： 目的研究冠状动脉旁路移植术（CABG）后患者出现血小板高反应性（HTPR）的相关影响因素，旨在为术后用药提供参考。方法选取2017年1月至2020年6月河南科技大学第一附属医院成功完成 CABG，术后使用氯吡格雷、阿司匹林治疗的 144例患者作为研究对象，其中男 110例，女 34例，年龄（55.85±7.18）岁，收集所有患者临床资料，按血小板聚集抑制率分为正常血小板反应性（NTPR）组116例、HTPR组28例。计量资料组间比较采用独立样本t检验，计数资料组间采用χ2 检验或 Fisher确切概率法，单因素、多因素分析筛选患者 HTPR 的可能危险因素。结果两组CABG患者年龄比较，差异有统计学意义（χ2 =19.153，P<0.001）。HTPR组术前血肌酐指标为（74.52±9.84）μmol/L，低于 NTPR 组（83.68±13.47）μmol/L，差异有统计学意义（P<0.05）。两组 CABG 患者手术时间、24 h引流量比较，差异均有统计学意义（χ2 =8.329、12.758，P<0.05）。HTPR组血块动力（K）、血块强度（MAADP）分别为（1.50±0.37）min、（49.84±6.28）mm，均高于NTPR组（1.21±0.24）min、（37.54±5.41）mm，血块动力（Alpha）、血块强度（MAthrombin）、凝血综合指数（CI）、花生四烯酸（AA）抑制率分别为（69.47±2.41）°、（64.24±2.51）mm、（1.85±0.54）、（63.28±18.63）%，均低于 NTPR 组（72.85±2.31）°、（66.86±2.74）mm、（2.97±0.92）、（79.74±16.59）%，差异均有统计学意义（均P<0.05）。多因素分析发现，年龄、性别、AA抑制率、血肌酐为 HTPR 的危险因素（均 P<0.05）。结论年龄、性别、AA 抑制率、血肌酐为 CABG 术后患者出现HTPR的危险因素，需进行相应预防，以期减少患者HTPR发生风险。

关键词: 冠状动脉旁路移植术, 抗血小板药物, 反应, 危险因素

Abstract: Objective To study the related influencing factors of high on-treatment platelet reactivity (HTPR) in patients after coronary artery bypass grafting (CABG) in order to provide references for postoperative drug application. Methods A total of 144 patients who successfully completed CABG and were treated with clopidogrel and aspirin after surgery in The First Affiliated Hospital of Henan University of Science and Technology from January 2017 to June 2020 were selected as the research subjects, including 110 males and 34 females, aged (55.85± 7.18) years. The clinical data of all patients were collected. According to the inhibition rate of platelet aggregation, they were divided into a normal on-treatment platelet reactivity (NTPR) group (116 patients) and a HTPR group (28 patients). Independent sample t test was used for comparison of the measurement data between groups, χ2 test or Fisher's exact probability method was used for comparison of the count data between groups, and univariate and multivariate analysis were used to screen the possible risk factors of HTPR in patients. Results The age of patients undergoing CABG was significantly different between the two groups (χ2 =19.153, P<0.001). The preoperative serum creatinine level in the HTPR group was (74.52±9.84) μmol/L, which was lower than that in the NTPR group [(83.68±13.47) μmol/L], with a statistically significant difference (P<0.05). There were statistically significant differences in the operation time and 24 h drainage volume between the two groups (χ2 =8.329, 12.758, both P<0.05). The blood clot motility (K) and blood clot intensity (MAADP) of the HTPR group were (1.50±0.37) min and (49.84±6.28) mm, respectively, which were higher than those of the NTPR group [(1.21±0.24) min and (37.54±5.41) mm]; the blood clot dynamics (Alpha), blood clot intensity (MAthrombin), coagulation composite index (CI), and the inhibition rate of arachidonic acid (AA) were (69.47±2.41)° , (64.24±2.51) mm, (1.85±0.54), and (63.28±18.63)% , respectively, which were lower than those of the NTPR group [(72.85±2.31)° , (66.86±2.74) mm, (2.97±0.92), and (79.74±16.59)%], with statistically significant differences (all P<0.05). Multivariate analysis showed that age, gender, AA inhibition rate, and serum creatinine were risk factors for HTPR (all P<0.05). Conclusion Age, gender, AA inhibition rate, and serum creatinine are risk factors for HTPR in patients after CABG, and corresponding prevention should be carried out to reduce the risk of HTPR in patients.

Key words: Coronary artery bypass grafting, Antiplatelet drugs, Reactivity, Risk factors

张彬彬. 冠状动脉旁路移植术后患者血小板高反应性的影响因素分析[J]. 国际医药卫生导报, 2022, 28(2): 247-250.

Zhang Binbin. Influencing factors of high on-treatment platelet reactivity after coronary artery bypass grafting[J]. International Medicine and Health Guidance News, 2022, 28(2): 247-250.

参考文献

[1] 董士勇,王进,张思宇,等 . 非体外循环冠状动脉旁路移植术联合中度以上创伤非心脏手术的围手术期安全性研究及可行性评价[J]. 中华外科杂志, 2021, 59(1): 46-51. DOI: 10.3760/cma.j.cn112139-20200408-00286.

[2] 田美策,王现强. 冠状动脉旁路移植术后静脉桥的衰败机制与通畅率改进措施的进展[J]. 中国循环杂志,2020,35(1): 98-101. DOI:10.3969/j.issn.1000-3614.2020.01.019.

[3] 方颖,韦华,吴震,等 . 主动脉内球囊反搏辅助不停跳冠状动脉旁路移植术在缺血性心肌病治疗中的应用[J]. 首都医科大学学报,2018,39(6):933-936. DOI:10.3969/j.issn.1006- 7795.2018.06.024.

[4] 庄晓鸣. 四参养心汤联合降胎、抗血小板治疗对冠状动脉狭窄患者心肌缺血反心电图的影响[J]. 四川中医,2017, 35(11):65-67.

[5] 王占志,田晓琴,颜茂发 . 血栓弹力图在糖尿病肾病维持性血液透析患者抗血小板药物反应性中的评估价值[J]. 血栓与止血学,2020,26(6):943-944. DOI:10.3969/j.issn.1009- 6213.2020.06.017.

[6] 铁远,刘蕾. 我院神经内科门诊抗血小板药物及中西药物联合使用的合理性分析[J]. 中国临床药学杂志,2017,26(6): 415-418.

[7] 石美鑫 . 实用外科学 [J]. 北京 :人民卫生出版社 , 2002: 269-273.

[8] 宋媛媛,徐骁晗,陆小虎,等 . 个体化全动脉冠状动脉旁路移植术的临床应用[J]. 南京医科大学学报(自然科学版), 2019,39(6):899-902. DOI:10.7655/NYDXBNS20190621.

[9] 罗智鸿,杨帆,杨鹏,等 . 富血小板血浆对股骨头坏死保髋术后凝血相关血液指标的影响[J]. 中国组织工程研究,2020, 24(15):2393-2398. DOI:10.3969/j.issn.2095-4344.2589.

[10] 唐细梅,张志能,肖纯,等 . 经皮冠状动脉介入患者氯吡格雷治疗后血小板高反应性的危险因素筛查及基因多态性研究[J]. 中国医药, 2020, 15(8): 1178-1182. DOI: 10.3760/j. issn.1673-4777.2020.08.007.

[11] 徐晓宇,石秀锦,续茜桥,等 . PON1 Q192R 年龄与性别对氯吡格雷抗血小板疗效与 PON1 Q192R 基因多态性相关性的影响[J]. 中国药物应用与监测,2017,14(3):146-150. DOI: 10.3969/j.issn.1672-8157.2017.03.005.

[12] 戴惠钦,洪雷,杜巧媚,等 . 抗血小板药物治疗冠心病病人中应用 CRUSADE 评分对消化系统出血风险的评估作用[J]. 蚌埠医学院学报,2020,45(3):345-347. DOI:10.13898/j. cnki.issn.1000-2200.2020.03.016.

[13] 赵金凤,阮志勇,徐燕,等 . 冠心病患者经皮冠状动脉介入术后应用抗凝、抗血小板作用药物分析[J]. 中国医院用药评价与分析 , 2015, 15(12): 1654-1657. DOI: 10.14009/j. issn.1672-2124.2015.12.031.

[14] 郭琳娟,姜醒华,贺文凤,等 . 冠心病患者 CYP2C19基因突变及其对氯吡格雷抗血小板反应中生物活化作用的影响[J]. 中华心血管病杂志,2021,49(1):43-48. DOI:10.3760/cma.j. cn112148-20200424-00345.

[15] 房晓楠,鲁洁,郑欣馨,等 . 经皮冠状动脉介入术后血小板高反应性的影响因素及预后评价[J]. 中国分子心脏病学杂志, 2018,18(4):2535-2538. DOI:10.16563/j.cnki.1671-6272. 2018.08.004.