【作者】 杨海娜；

【导师】 王伟；

【作者基本信息】 天津医科大学 ， 内科学， 2011， 硕士

【摘要】 目的通过对检查血栓弹力图(TEG)的冠状动脉介入治疗患者临床病历的回顾性调查研究,对不同临床分型的冠心病患者凝血特点进行分析,并对PCI术后可能发生抗血小板药物反应低下及近期缺血事件的相关危险因素进行分析总结,探讨TEG在冠状动脉介入治疗患者抗血小板治疗监测中的应用价值及实用性。方法入选2010年10月1日至2011年1月31日间在天津胸科医院临床资料相对完整、行PCI治疗并应用TEG监测抗血小板疗效的冠心病患者150例,据冠心病临床分型标准分为急性心肌梗死(AMI)组、不稳定型心绞痛(UAP)组、稳定型心绞痛(AP)组,比较分析各组间TEG、凝血全项指标的差异；据PCI术后TEG检测的血小板聚集抑制率不同,分为抗血小板约物反应低下组和抗血小板药物反应正常组,比较分析可能发生抗血小板药物反应低下的相关危险因素；据出院三月内有无缺血事件分为有事件组和无事件组,比较分析可能发生近期缺血事件的相关危险因素。结果1、入选的150例患者平均年龄61.35±10.41岁(44-84岁),其中AMI组51例,占总数的34.00%；UAP组86例,占总数的57.33%；AP组13例,占总数的8.67%。(1)AMI组、UAP组与AP组比较,TEG的常规参数：R值、K值明显缩短,MA值、Angle明显增大,TEG高凝图形出现的比例明显增高,P均<0.01,差异有统计学意义；(2)D-二聚体在AMI组、UAP组以及AP组三组间有差异,P均<0.05,差异有统计学意义；(3)在AMI组活化部分凝血活酶时间(APTT)、国际标准化比值(INR)明显减低,与UAP组、AP组比较,P均<0.05,差异有统计学意义。2、抗血小板药物反应低下组(包括氯吡格雷反应低下和阿司匹林反应低下)中糖尿病患者、吸烟者所占的比例较抗血小板药物反应正常组明显增高,P均<0.05,差异有统计学意义。Logistic多元回归分析显示糖尿病、吸烟为抗血小板药物反应低下的独立危险因素。3、与无事件组比较,有事件组Fgb增高,TEG检测ADP诱导的血小板聚集抑制率明显减低,P均<0.05,差异有统计学意义。Logistic多元回归分析显示Fgb、氯吡格雷反应低下是近期缺血事件的独立危险因素。结论：1、AMI组、UAP组与AP组相比,TEG高凝图形所占比例明显增高,TEG常规参数R值、K值缩短,MA值、Angle增大,呈现相对的高凝状态,以AMI组为著,对于AMI和UAP患者,需给予充分的抗凝治疗。2、糖尿病患者易发生抗血小板药物反应低下,行PCI且合并糖尿病的冠心病患者应积极控制血糖,及早加用三联抗血小板治疗。3、吸烟可能影响血小板对氯吡格雷的反应性。4、近期缺血事件可能与氯吡格雷反应低下、Fgb增高有关,据TEG对血小板聚集抑制率的监测指导抗血小板用药,并积极降纤治疗,近期缺血事件可能减少。5、TEG对PCI患者抗血小板的治疗监测有一定应用价值。更多还原

【Abstract】 ObjectiveAccording to the retrospective investigation into clinical records of patients who accepted the percutaneous coronary intervention(PCI) undergoning the thrombelastogram examination,We analyzed the feature of clotting in different clinical types of CHD patients,the relevant factors of low reaction to antiplatelet drugs and recent ischemia events in patients who accepted PCI and discussed the significance and practical applicability of TEG to antiplatelet therapy monitoring in the patients who accepted PCI.Methods150 CHD patients with relatively complete clinical data were adopted who had accepted PCI and monitored antiplatelet therapy with TEG in Tianjin Chest Hospital from Oct 1st,2010 to Jan 31st,2011.The patients were divided into Acute Myocardial Infarction (AMI) group,Unstable Angina Pectoris (UAP) group and Angina Pectoris (AP) group according to CHD clinical classification.To analysis the differences in TEG & coagulation test among the groups.All patients were divided into low reaction group and normal group according to the platelet agglutination inhibition rate examed by TEG after PCI.To analyze the related factors that may affect the reaction to antiplatelet drugs.We divided all the patients into incident group and non-incident group according to whether ischemia events happened in three months after hospitalization.To analyze the related factors that may have influence on recent ischemia events.Results1. The average age of the 150 patients were 61.35±10.41 (44-84 years old). There were 51 patients (34.00%) in AMI group,86 patients (57.33%) in UAP group,13 patients (8.67%) in AP group.(1)Compared with AMI group,the R and K value cut short (P<0.05),and both MA and Angle value amplified (P<0.05),the frequency of high coagulate images of TEG obviously get much higher(P<0.01) in UAP group and AP group.(2)There were significance differents in D-dimer among AMI group, UAP group and AP group.(3)Activated Partial Thromboplastin Time (APTT) and International Normalized Radio (INR) were reduced obviously in AMI group which compared with UAP group and AP group (P<0.05).2. Proportion of diabetics and smokers were obvious higher in low reaction to antiplatelet drugs group than in normal group (P<0.05).Logistic multiple regression analysis showed that diabetic and smoke were independent factors of low reaction to antiplatelet drugs.3. Fgb value got much higher and the platelet agglutination inhibition rate which were induced by ADP in event group was obviously lower than in non-event group (P<0.05).Logistic multiple regression analysis showed that Fgb and low reaction to clopidogrel were independent factors of recent ischemia events.Conclusions1. AMI and UAP-especially AMI-were relative more hypercoaguloability image and R, K get shorter and MA,Angle get much more in TEG when that compared with AP.Sufficient anticoagulation therapy must be given to the patients who have AMI and UAP.2. Low reaction of antiplatelet drugs tends to occur in diabetic patients.The CHD patients with diabetes should control their blood sugar and add trigeminy resist platelet treatment much earlier when they received PCI.3. Smoking probably has influence on the reactivity of platelet to clopidogrel.4. Recent ischemia events were probably related to low reaction to clopidogrel and Fgb.Using antiplatelet drugs according to monitoring the platelet agglutination inhibition rate and decreasing the fibrinogen concentration may reduce the recent ischemia events.5. TEG is helpful in monitoring antiplatelet therapy in the patients who accepted PCI.更多还原