冠状动脉介入治疗患者不同年龄人群双联抗血小板评分的分布特点及预后
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摘要
目的:双联抗血小板(DAPT)评分,是指导冠状动脉动脉介入术后DAPT的有效工具,年龄是评分系统中重要的因素,但年龄对预后的影响及不同年龄的患者DAPT评分的分布特点并不清楚。通过单中心大样本队列研究,观察不同年龄组的PCI患者临床预后及DAPT评分的分布。方法:连续入选我院14 990例接受PCI的患者,所有患者按年龄分为三组:≥75岁(n=1 591),65～75岁(n=4 217)以及<65岁(n=9 182)。调查三组患者心肌梗死、支架血栓及GUSTO中重度出血的发生率,以及DAPT评分的分布特点。结果:在中位19. 4个月的随访时间中,三组患者支架血栓及心肌梗死的发生率均差异无统计学意义。和年轻患者相比,年龄65～75岁和≥75岁均是GUSTO中重度出血的预测因素(65～75岁HR=2. 05,95%CI:1. 46～2. 88;≥75岁HR=3. 35,95%CI:1. 52～7. 39)。随着年龄组的增加,DAPT评分中位数均减少1分。DAPT评分≥2分的患者在<65岁的患者中占到63. 5%,在65～75岁患者中占32. 6%,而在≥75岁的老年患者中仅占到13. 2%。结论:老年患者PCI术后不增加心肌梗死及支架血栓的风险,但出血事件明显增加。与年轻患者相比,老年患者DAPT评分更低,≥2分的比例更低。
Objective: Dual antiplatelet therapy( DAPT) score has been established as a tool to guide the extended dual antiplatelet therapy after percutaneous coronary intervention( PCI),in which age is one of the factors. To examine the impact of age on ischemic and bleeding risk as well as DAPT score distribution among patients undergoing PCI. Methods: A total of 14 990 patients undergoing PCI were stratified according to their ages: ≥75 years( n = 1 591),65 to <75 years( n = 4 217) and <65 years( n = 9 182). The risk of myocardial infarction,stent thrombosis,GUSTO moderate or severe bleeding and DAPT score distribution was compared among the three age groups. Results: During median 19. 4 months of follow-up,the risks of myocardial infarction and stent thrombosis were both similar among the three groups. Compared with young patients,age of65-75 and age ≥75 were both independent risk factors of GUSTO moderate or severe bleeding( 65-75 HR =2. 05,95% CI: 1. 46-2. 88; ≥75 HR = 3. 35,95% CI: 1. 52-7. 39). DAPT score distribution is different among patients in different ages,with a consistent 1 point decrease in the median score for each level increase of age category. Patients with DAPT Score ≥ 2 accounted for 63. 5% of patients < 65 years of age,compared to the proportion of 13. 2% in those ≥ 75 years. Conclusions: Among patients undergoing PCI,older age is not an independent risk factor for myocardial infarction and stent thrombosis,but increases risk of bleeding. Compared with young patients,patients with older age have lower DAPT score and lower proportion of those with DAPT score ≥2.
Objective: Dual antiplatelet therapy( DAPT) score has been established as a tool to guide the extended dual antiplatelet therapy after percutaneous coronary intervention( PCI),in which age is one of the factors. To examine the impact of age on ischemic and bleeding risk as well as DAPT score distribution among patients undergoing PCI. Methods: A total of 14 990 patients undergoing PCI were stratified according to their ages: ≥75 years( n = 1 591),65 to <75 years( n = 4 217) and <65 years( n = 9 182). The risk of myocardial infarction,stent thrombosis,GUSTO moderate or severe bleeding and DAPT score distribution was compared among the three age groups. Results: During median 19. 4 months of follow-up,the risks of myocardial infarction and stent thrombosis were both similar among the three groups. Compared with young patients,age of65-75 and age ≥75 were both independent risk factors of GUSTO moderate or severe bleeding( 65-75 HR =2. 05,95% CI: 1. 46-2. 88; ≥75 HR = 3. 35,95% CI: 1. 52-7. 39). DAPT score distribution is different among patients in different ages,with a consistent 1 point decrease in the median score for each level increase of age category. Patients with DAPT Score ≥ 2 accounted for 63. 5% of patients < 65 years of age,compared to the proportion of 13. 2% in those ≥ 75 years. Conclusions: Among patients undergoing PCI,older age is not an independent risk factor for myocardial infarction and stent thrombosis,but increases risk of bleeding. Compared with young patients,patients with older age have lower DAPT score and lower proportion of those with DAPT score ≥2.
引文
[1]Singh M,Peterson ED,Roe MT,et al.Trends in the association between age and in-hospital mortality after percutaneous coronary intervention:national cardiovascular data registry experience.Circ Cardiovasc Interv,2009,2(1):20-26.
[2]Johnman C,Oldroyd KG,Mackay DF,et al.Percutaneous coronary intervention in the elderly:changes in case-mix and periprocedural outcomes in 31,758 patients treated between 2000 and2007.Circ Cardiovasc Interv,2010,3(4):341-345.
[3]Cohen HA,Williams DO,Holmes DR Jr,et al.NHLBI Dynamic Registry.Impact of age on procedural and 1-year outcome in percutaneous transluminal coronary angioplasty:a report from the NHLBI Dynamic Registry.Am Heart J,2003,146(3):513-519.
[4]Guagliumi G,Stone GW,Cox DA,et al.Outcome in elderly patients undergoing primary coronary intervention for acute myocardial infarction:results from the Controlled Abciximab and Device Investigation to Lower Late Angioplasty Complications(CADIL-LAC)trial.Circulation,2004,110(12):1598-1604.
[5]Silvain J,Cayla G,Hulot JS,et al.High on-thienopyridine platelet reactivity in elderly coronary patients:the SENIOR-PLATELET study.Eur Heart J,2012,33(10):1241-1249.
[6]Nikolsky E,Mehran R,Dangas G,et al.Development and validation of a prognostic risk score for major bleeding in patients undergoing percutaneous coronary intervention via the femoral approach.Eur Heart J,2007,28(16):1936-1945.
[7]Mehran R,Pocock SJ,Nikolsky E,et al.A risk score to predict bleeding in patients with acute coronary syndromes.J Am Coll Cardiol,2010,55(23):2556-2566.
[8]Wallentin L,Goldstein P,Armstrong PW,et al.Efficacy and safety of tenecteplase in combination with the low molecularweight heparin enoxaparin or unfractionated heparin in the prehospital setting:the assessment of the safety and efficacy of a new thrombolytic regimen(ASSENT)-3 PLUS randomized trial in acute myocardial infarction.Circulation,2003,108:135-142.
[9]Wiviott SD,Braunwald E,Mc Cabe CH,et al.TRITON-TIMI 38Investigators.Prasugrel versus clopidogrel in patients with acute coronary syndromes.N Engl J Med,2007,357:2001-2015.
[10]李秋敏,刘凯,李元玲等.年龄对血小板和淋巴细胞比值与冠心病关系的影响性研究.心肺血管病杂志,2018,37(8):751-756.
[11]Mauri L,Kereiakes DJ,Yeh RW,et al.DAPT Study Investigators.Twelve or 30 months of dual antiplatelet therapy after drugeluting stents.N Engl J Med,2014,371(23):2155-2166.
[12]Kereiakes DJ,Yeh RW,Massaro JM,et al.Dual Antiplatelet Therapy(DAPT)Study Investigators.Antiplatelet therapy duration following bare metal or drug-eluting coronary stents:the dual antiplatelet therapy randomized clinical trial.JAMA,2015,313(11):1113-1121.
[13]Yeh RW,Secemsky EA,Kereiakes DJ,et al.DAPT Study Investigators.Development and validation of a prediction rule for benefit and harm of dual antiplatelet therapy beyond 1 year after percutaneous coronary intervention.JAMA,2016,315(16):1735-1749.
[14]Wiemer M,Langer C,Kottmann T,et al.Outcome in the elderly undergoing percutaneous coronary intervention with sirolimus-eluting stents:results from the prospective multicenter german cypher stent registry.Am Heart J,2007,154(4):682-687.
[2]Johnman C,Oldroyd KG,Mackay DF,et al.Percutaneous coronary intervention in the elderly:changes in case-mix and periprocedural outcomes in 31,758 patients treated between 2000 and2007.Circ Cardiovasc Interv,2010,3(4):341-345.
[3]Cohen HA,Williams DO,Holmes DR Jr,et al.NHLBI Dynamic Registry.Impact of age on procedural and 1-year outcome in percutaneous transluminal coronary angioplasty:a report from the NHLBI Dynamic Registry.Am Heart J,2003,146(3):513-519.
[4]Guagliumi G,Stone GW,Cox DA,et al.Outcome in elderly patients undergoing primary coronary intervention for acute myocardial infarction:results from the Controlled Abciximab and Device Investigation to Lower Late Angioplasty Complications(CADIL-LAC)trial.Circulation,2004,110(12):1598-1604.
[5]Silvain J,Cayla G,Hulot JS,et al.High on-thienopyridine platelet reactivity in elderly coronary patients:the SENIOR-PLATELET study.Eur Heart J,2012,33(10):1241-1249.
[6]Nikolsky E,Mehran R,Dangas G,et al.Development and validation of a prognostic risk score for major bleeding in patients undergoing percutaneous coronary intervention via the femoral approach.Eur Heart J,2007,28(16):1936-1945.
[7]Mehran R,Pocock SJ,Nikolsky E,et al.A risk score to predict bleeding in patients with acute coronary syndromes.J Am Coll Cardiol,2010,55(23):2556-2566.
[8]Wallentin L,Goldstein P,Armstrong PW,et al.Efficacy and safety of tenecteplase in combination with the low molecularweight heparin enoxaparin or unfractionated heparin in the prehospital setting:the assessment of the safety and efficacy of a new thrombolytic regimen(ASSENT)-3 PLUS randomized trial in acute myocardial infarction.Circulation,2003,108:135-142.
[9]Wiviott SD,Braunwald E,Mc Cabe CH,et al.TRITON-TIMI 38Investigators.Prasugrel versus clopidogrel in patients with acute coronary syndromes.N Engl J Med,2007,357:2001-2015.
[10]李秋敏,刘凯,李元玲等.年龄对血小板和淋巴细胞比值与冠心病关系的影响性研究.心肺血管病杂志,2018,37(8):751-756.
[11]Mauri L,Kereiakes DJ,Yeh RW,et al.DAPT Study Investigators.Twelve or 30 months of dual antiplatelet therapy after drugeluting stents.N Engl J Med,2014,371(23):2155-2166.
[12]Kereiakes DJ,Yeh RW,Massaro JM,et al.Dual Antiplatelet Therapy(DAPT)Study Investigators.Antiplatelet therapy duration following bare metal or drug-eluting coronary stents:the dual antiplatelet therapy randomized clinical trial.JAMA,2015,313(11):1113-1121.
[13]Yeh RW,Secemsky EA,Kereiakes DJ,et al.DAPT Study Investigators.Development and validation of a prediction rule for benefit and harm of dual antiplatelet therapy beyond 1 year after percutaneous coronary intervention.JAMA,2016,315(16):1735-1749.
[14]Wiemer M,Langer C,Kottmann T,et al.Outcome in the elderly undergoing percutaneous coronary intervention with sirolimus-eluting stents:results from the prospective multicenter german cypher stent registry.Am Heart J,2007,154(4):682-687.