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目的经皮冠状动脉介入治疗(percutaneous coronary intervention,PCI)围手术期心肌梗死的发生与术前抗栓治疗关系密切,但至今还没有理想的临床指标评价PCI术前的抗栓治疗效果。Sonoclot是一种以血液黏度为基础体外实时监测凝血功能和血小板功能的方法。本研究拟入选急性冠状动脉综合征(ACS)患者,PCI术前进行Sonoclot检测,评价Sonoclot指标与PCI围手术期心肌梗死发生的相关性,寻找可以评价PCI术前抗栓疗效的指标。方法前瞻性连续入选2009年9月至2010年7月收住在北京大学第一医院心内科、临床诊断为非ST段抬高急性冠脉综合征并接受冠状动脉造影及介入治疗的患者。收集一般临床资料,根据PCI术后心肌标记物升高至正常值上限3倍以上与否判断患者是否发生围手术期心肌梗死,使用Sonoclot凝血及血小板功能分析仪(Sonoclot coagulation&platelet function analyzer,SCA,SIENCO,Inc,USA)完成ACT(activited clotting time,激活凝血时间)、CR(clot rate,凝血速率)、PF(platelet function,血小板功能)等指标的检测。结果共入组患者246例,其中,男性163例(66.3%),女性83例(33.7%),年龄分布于27～87岁之间,平均(64.3±11.2)岁。其中119例(48.4%)发生围手术期心肌梗死,与未发生者相比,性别、术中肝素用量、多支血管病变比例差异具有统计学意义。另外,经Sonoclot测得的肝素化前CR(gbCR)在两组间差异存在统计学意义(21.32比19.83,t=-2.000,P<0.05)。进一步按照gbCR的75%分位数(gbCR=24)将患者分为两组,结果显示,gbCR高于四分位数患者围手术期心梗风险明显增加(OR:1.94,95%CI:1.05～3.59,P=0.04)。对性别、年龄、BMI、多支血管病变、肝素用量、PT值、FIB值、gbCR等多个因素进行Logistic回归分析显示,gbCR是PCI围手术期心梗的独立预测因素(OR=2.36,95%CI:1.05～5.28)。结论肝素化前CR值与PCI围手术期心肌梗死具有显著相关性,提示对该指标的监测可能会预测PCI围术期心肌梗死的发生风险。
Objective Percutaneous coronary intervention (percutaneous coronary intervention, PCI) perioperative myocardial infarction with preoperative antithrombotic therapy is closely related, but so far no ideal clinical evaluation of PCI preoperative antithrombotic effect. Sonoclot is a method of real-time monitoring of coagulation and platelet function in vitro based on blood viscosity. This study intends to enrolle patients with acute coronary syndrome (ACS), before PCI Sonoclot test to evaluate the correlation between Sonoclot index and PCI perioperative myocardial infarction, in order to find an index for evaluation of antithrombotic efficacy before PCI. Methods The patients were prospectively enrolled in the Department of Cardiology of the First Hospital of Peking University from September 2009 to July 2010, and were clinically diagnosed as non-ST segment elevation acute coronary syndrome undergoing coronary angiography and interventional therapy. General clinical data were collected. Peripheral myocardial infarction was determined according to whether the myocardial marker increased to more than 3 times the upper limit of normal after PCI. Sonoclot coagulation & platelet function analyzer (SCA, SIENCO , Inc, USA) to detect the indicators such as the activated clotting time (ACT), the clot rate (CR), and the platelet function (PF). Results A total of 246 patients were enrolled. Among them, 163 (66.3%) were males and 83 (33.7%) females. The age distribution ranged from 27 to 87 years old (64.3 ± 11.2) years old. Perioperative myocardial infarction occurred in 119 patients (48.4%). There was significant difference in gender, intraoperative heparin dosage and multivessel disease ratio among those with no myocardial infarction. In addition, pre-heparin CR (gbCR) measured by Sonoclot was statistically different between the two groups (21.32 vs. 19.83, t = -2.000, P <0.05). Patients were further divided into two groups based on a 75% quantile of gbCR (gbCR = 24). The results showed that the risk of perioperative MI was significantly increased in patients with gbCR higher than quartiles (OR: 1.94, 95% CI: 1.05 ~ 3.59, P = 0.04). Logistic regression analysis of multiple factors such as gender, age, BMI, multivessel disease, heparin, PT, FIB, gbCR showed that gbCR was an independent predictor of PCI perioperative MI (OR = 2.36,95 % CI: 1.05 ~ 5.28). Conclusions There is a significant correlation between pre-heparin CR value and PCI perioperative myocardial infarction, which indicates that the monitoring of this index may predict the risk of perioperative myocardial infarction.