天津医药

天津医药 ›› 2017, Vol. 45 ›› Issue (9): 948-952.

• 临床研究 • 上一篇    下一篇

术前持续双联抗血小板治疗对非体外循环下冠状动脉旁路移植术近期预后的影响

李志龙 1，王联群 2，郭志刚 2△   

  1. 1 天津医科大学（邮编 300070）；2 天津市胸科医院心脏外科，天津市心血管病研究所
  • 收稿日期:2017-06-09 修回日期:2017-08-30 出版日期:2017-09-15 发布日期:2017-09-25
  • 通讯作者: 李志龙 E-mail:lizhilong42024024@163.com
  • 基金资助:
    天津市卫生行业重点攻关项目

Effects of preoperative continued dual antiplatelet therapy on early outcomes in patients undergoing off-pump coronary artery bypass grafting

LI Zhi-long1, WANG Lian-qun2, GUO Zhi-gang2△   

  • Received:2017-06-09 Revised:2017-08-30 Published:2017-09-15 Online:2017-09-25
  • Contact: Zhilong Li E-mail:lizhilong42024024@163.com
  • Supported by:
    Fund of Tianjin Municipal Bureau of Health

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摘要： 目的 评估术前持续服用阿司匹林和氯吡格雷的双联抗血小板治疗（DAPT）对非体外循环下冠状动脉旁路移植术（OPCABG）患者近期预后的影响。方法 本研究为单中心观察性研究。纳入279例2015年1月至2016年5月期间在天津市胸科医院进行初次单纯非体外循环下心脏不停跳冠状动脉旁路移植术的患者，按照术前双联抗血小板治疗（DAPT）情况将其分成两组：一组患者持续DAPT至术前1天DAPT组（n = 148）；另一组患者OPCABG术前停用DAPT 5天（对照组, n = 131）。搜集两组患者基线资料，术后总引流量、出血剖胸探查发生率、血制品输注以及其他住院期间的临床结果资料进行比较和统计学分析。结果 两组患者人口学特征和临床基线资料无显著差异。DAPT组患者在术后总的胸腔引流量 (DAPT 组vs.对照组，899 ± 227 mL vs. 801 ± 242 mL, P = 0.001) 和围术期血制品输注(包括输血比例和输血量) 上都明显高于对照组。两组患者术后出血所致剖胸探查发生率(DAPT 组vs.对照组，3.4% vs. 0.8%, P=0.219)，手术时间（DAPT 组vs.对照组，4.932 ± 0.69 vs. 4.82 ± 0.69，P=0.168），ICU停留时间（DAPT 组vs.对照组，51.82± 13.95 h vs. 50.56± 13.04 h, P=0.434）,气管内插管时间 (DAPT 组vs.对照组，16.23 ± 2.57 h vs. 16.12 ± 2.61 h, P=0.729), 术后住院天数(DAPT 组vs.对照组，10.6 ± 5.4 d vs. 9.6 ± 4.8 d, P=0.108)，术后非致死性心肌梗死发生率(DAPT组vs.对照组, 4.7% vs. 3.8%, P=0.708)均无明显统计学差异。术后住院期间未观察到卒中和其他严重的胸外出血，两组患者术后住院期间均无死亡病例。结论 OPCABG患者术前持续服用双联抗血小板治疗会增加术后胸腔引流液和血制品输注需求但不具有显著临床意义。双联抗血小板治疗持续至术前不增加出血剖胸探查发生率,不影响OPCABG患者的近期预后和术后恢复。如果临床情况许可，拟行初次单纯OPCABG的患者术前持续服用双联抗血小板药物是安全的。

关键词: 非体外循环, 冠状动脉旁路移植术, 双联抗血小板治疗, 阿司匹林, 氯吡格雷

Abstract: Objective This study sought to evaluate the effects of preoperative continued dual antiplatelet therapy (DAPT) with aspirin and clopidogrel on early outcomes in patients undergoing off-pump coronary artery bypass grafting (OPCABG). Methods We conducted an observational cohort study of 279 patients who underwent first-time isolated OPCABG from January 2015 to May 2016 at our institution. Patients were divided into two groups, in which preoperative DAPT was given until the time of surgery (DAPT group, n = 148) or was stopped for 5 days before surgery (control group, n = 131). Baseline characteristics, total chest-tube output, rate of re-exploration for bleeding, blood-product transfusion requirements, and other perioperative and postoperative data were collected and compared. Results Demographic and preoperative clinical characteristics were similar in both groups. Total chest-tube drainage volume (DAPT group vs. control group, 899 ± 227 mL vs. 801 ± 242 mL, P = 0.001) and perioperative transfusion requirements (rate and volume) were statistically higher in the continued DAPT group compared to the control group. There were no significant differences between the groups in hemostatic re-exploration rate (DAPT group vs. control group, 3.4% vs. 0.8%, P=0.219), length of operation (DAPT group vs. control group, 4.932 ± 0.69 h vs. 4.82 ± 0.69 h， P=0.168)，ICU stay (DAPT group vs. control group, 51.82± 13.95 h vs. 50.56± 13.04 h, P=0.434), ventilation time (DAPT group vs. control group, 16.23 ± 2.57 h vs. 16.12 ± 2.61 h, P=0.729), duration of postoperative hospitalization (DAPT group vs. control group, 10.6 ± 5.4 d vs. 9.6 ± 4.8 d, P=0.108), postoperative nonfatal myocardial infarction (DAPT group vs. control group, 4.7% vs. 3.8%, P=0.708). Stroke and other severe outside chest bleeding and all-cause mortality were not observed in both groups during the postoperative period, prior to discharge. Conclusions Preoperative continued DAPT is associated with increased chest-tube drainage and higher blood-product transfusion requirements but not significant clinically. This antiplatelet strategy does not alter other investigated outcomes in primary isolated OPCABG patients. If clinically indicated, preoperative DAPT may be able to be safely continued in patients referred for primary isolated OPCABG.

Key words: off-pump, CABG, dual antiplatelet therapy, aspirin, clopidogrel.