老年急性心肌梗死患者氯吡格雷抵抗的相关因素及其对预后的影响
Related factors of clopidogrel resistance and its impact on prognosis in elderly patients with acute myocardial infarction
孙磊 1徐敏 2陈珊珊 1王超君3
作者信息
- 1. 230000 合肥,联勤保障部队第九○一医院院前急救科
- 2. 230000 合肥,联勤保障部队第九○一医院心内科
- 3. 空军杭州特勤疗养中心疗养一区药械科
- 折叠
摘要
目的 探讨老年急性心肌梗死患者氯吡格雷抵抗的危险因素,为接受氯吡格雷治疗的患者提供个体化用药方案.方法 前瞻性选取2018年1月至2022年12月联勤保障部队第九O 一医院和空军杭州特勤疗养中心收治的老年急性心肌梗死患者472例,均接受冠状动脉支架置入术;术后给予氯吡格雷抗血小板治疗,连续7 d后取外周静脉血测定氯吡格雷活性代谢产物浓度和血小板最大聚集率(arachadonic acid-induced maximum platelet aggre-gation ratio,MARA A),根据MARAA,分为氯吡格雷抵抗组142例(MARAA≥55％)和氯吡格雷敏感组330例(＜55％).比较2组临床特征,采用多因素logistics回归分析氯吡格雷抵抗的危险因素,并分析氯吡格雷抵抗对重大不良心血管事件的影响.结果 与氯吡格雷敏感组比较,氯吡格雷抵抗组MARAA水平显著增高;与氯吡格雷敏感组比较,氯吡格雷抵抗组氯吡格雷活性代谢产物浓度显著降低.氯吡格雷抵抗组体质量指数、肥胖、细胞色素P450(cytochrome P450,CYP)2C19*2突变、糖尿病、高脂血症、降糖药物比例显著高于氯吡格雷敏感组,差异有统计学意义(P＜0.01).肥胖、糖尿病、高脂血症和CYP2C19*2突变是老年急性心肌梗死患者氯吡格雷抵抗的危险因素(OR=2.036,95％CI:1.282～3.235;OR=2.795,95％CJ:1.803～4.334;OR=2.125,95％CI:1.355～3.331;OR=4.881,95％CI:2.807～8.486).与氯吡格雷敏感组比较,氯吡格雷抵抗组重大不良心血管事件发生率显著增高(11.27％vs 4.55％,P＜0.01).采用R4.0.3统计软件构建预测模型,将数据集随机抽取330例作为训练集,剩余142例作为验证集;训练集ROC曲线下面积为0.750,验证集ROC曲线下面积为0.780;对模型进行Hosmer-Lemeshow Goodness-of-Fit检验(x2=18.907,P=0.215),说明本模型具有较好的可信度和预测价值.结论 肥胖、糖尿病、高脂血症和CYP2C19*2突变是老年急性心肌梗死患者氯吡格雷抵抗的危险因素,氯吡格雷抵抗可导致患者预后不良.
Abstract
Objective To explore the risk factors of clopidogrel resistance in elderly patients with acute myocardial infarction(AMI)in order to provide personalized medication plans.Methods A prospective trial was conducted on 472 elderly AMI patients undergoing coronary stent placement in No.901 Hospital of Joint Logistics Support Force of PLA and Hangzhou Special Service Conva-lescent Center of Air Force from January 2018 to December 2022.All patients received clopidogrel for antiplatelet postoperatively,and after 7 consecutive days of administration,peripheral venous blood samples were collected to observe whether the patient had resistance to clopidogrel and to measure the concentration of active metabolites of clopidogrel and the maximum platelet aggrega-tion ratio(MARAA)of arachidonic acid induced platelets.According to MARAA,they were divid-ed into a clopidogrel resistant group(MARAA≥55％,142 cases)and a clopidogrel sensitive group of(＜55％,330 cases).The clinical characteristics were compared between the two groups,and multivariate logistic regression analysis was used to identify the risk factors for clopidogrel resistance.The impact of clopidogrel resistance on major adverse cardiovascular events was ana-lyzed.Results The clopidogrel resistant group had significantly higher MARAA level,decrease in the concentration of clopidogrel active metabolites,higher BMI,and larger ratios of obesity,CYP2C19*2 mutation,diabetes,hyperlipidemia and administration of hypoglycemic drugs when compared with the clopidogrel sensitive group(P＜0.01).Obesity,diabetes,hyperlipidemia and CYP2C19*2 mutation were risk factors for clopidogrel resistance in elderly AMI patients(OR=2.036,95％CI:1.282-3.235;OR=2.795,95％CI:1.803-4.334;OR=2.125,95％CI:1.355-3.331;OR=4.881,95％CI:2.807-8.486).The incidence of major adverse cardiovascular events was notably higher in the clopidogrel resistant group than the sensitive group(11.27％vs 4.55％,P＜0.01).After a prediction model was constructed with R4.0.3 statistical software,330 cases randomly selected from the dataset were assigned into a training set,and the remaining 142 cases into a validation set.The AUC value of the training set and the validation set was 0.750 and 0.780,respectively.Hosmer-Lemeshow Goodness of Fit test indicated that the model had good re-liability and predictive value(Chi-square=18.907,P=0.215).Conclusion Obesity,diabetes,hy-perlipidemia and CYP2C19*2 mutation are risk factors of clopidogrel resistance in elderly AMI patients,and clopidogrel resistance may lead to poor prognosis.
关键词
心肌梗死/氯吡格雷/支架/预后Key words
myocardial infarction/clopidogrel/stents/prognosis引用本文复制引用
出版年
2025
NETL
NSTL
万方数据