急性心肌梗死患者介入治疗后血小板高反应性临床危险因素评分构建

目的 建立预测急性心肌梗死患者介入治疗后血小板高反应性的临床危险因素评分，指导临床个体化抗血小板治疗。方法 纳入2013年1月至12月于北京协和医学院阜外医院行冠脉介入术治疗的547例急性心肌梗死患者，收集患者的一般临床资料及术后血栓弹力图。将血栓弹力图最大凝块强度（TEG-MAADP）>47 mm定义为存在血小板高反应性。利用患者临床常用指标筛选与血小板高反应性相关的危险因素，将多因素logistic回归分析中P< 0.05的临床指标纳入血小板高反应性危险评分模型，依据比值比（OR）赋予相应分值。结果 547例患者中230例（42.05%）存在血小板高反应性，TEG-MAADP值高于非血小板高反应性患者[（56.16±6.57） mm vs（26.43±13.88） mm，P<0.001]。单因素和多因素logistic回归分析发现，高龄（>75岁）、女性、合并糖尿病是血小板高反应性的独立危险因素。依据OR值权重赋予高龄（>75岁）3分，女性和合并糖尿病各赋2分，分值范围0~7分。依据得分将患者分为3组：0~2分组、3~5分组和6~7分组，结果显示3组间血小板反应性差异有统计学意义，0~2分组患者的血小板反应性低于3~5分和6~7分组[（37.79±18.45） mm vs（50.04±15.91） mm vs（56.50±15.78） mm；P<0.001]。受试者工作特征曲线分析显示得分>2分能有效预测是否存在血小板高反应性（曲线下面积为0.627，95%CI 0.579~0.675，P<0.001）。结论 临床风险评分能帮助快速识别可能存在血小板高反应性的患者，从而指导抗血小板个体化治疗。
Objective To construct a risk score for predicting high on-treatment platelet reactivity (HTPR) in patients with acute myocardial infarction after percutaneous coronary intervention, so as to guide individualized antiplatelet therapy. Methods A total of 547 patients with acute myocardial infarction undergoing percutaneous coronary intervention in Fuwai Hospital from Jan. 2013 to Dec. 2013 were enrolled in this study, and their general clinical data and post-operative thrombelastograms (TEG) were collected. The HTPR was defined as ADP-induced platelet-fibrin clot strength (MAADP) by TEG (TEG-MAADP)>47 mm. Clinical factors available in daily routine were analyzed to screen the related risk factors of HTPR. Clinical factors with a significance level of P<0.05 related to HTPR by multivariate logistic analysis were included in risk score model. The scores of variables were determined based on the odds ratio (OR) values. Results Among 547 patients, 230(42.05%) had HTPR, the TEG-MAADP was significantly higher than that of non-HTPR patients ([56.16±6.57] mm vs[26.43±13.88] mm, P<0.001). Univariate and multivariate logistic regression analysis showed that the three following factors were independent risk factors of HTPR:older age (>75 years) was weighted by score 3, female and diabetes mellitus both by score 2 according to OR values, thus a score ranging from 0 to 7 was developed to predict HTPR. The platelet reactivity (TEG-MAADP) was (37.79±18.45) mm, (50.04±15.91) mm and (56.50±15.78) mm for score 0-2, 3-5 and 6-7 patients, respectively, and it showed a significant difference among three score ranges (P<0.001). Receiver operating characteristic curve analysis showed that the score>2 was the best cut-off value to predict HTPR (area under the curve was 0.627,95% CI 0.579-0.675,P<0.001). Conclusion Clinical