Ebrahimi R， Dyke C， Mehran R， Manoukian SV， Feit F， Cox DA， Gersh BJ， Ohman EM， White HD， Moses JW， Ware JH， Lincoff AM， Stone GW.
University of California Los Angeles and the Greater Los Angeles VA Medical Center， Department of Medicine， Cardiology Section (111E)， Los Angeles， California 90073， USA. ebrahimi@UCLA.edu
Abstract
OBJECTIVES: This study sought to evaluate the impact of upstream clopidogrel in patients with non-ST-segment elevation acute coronary syndromes (NSTE-ACS) requiring coronary artery bypass grafting (CABG) from the ACUITY (Acute Catheterization and Urgent Intervention Triage strategY) trial.
BACKGROUND: Despite benefits of clopidogrel in patients with NSTE-ACS undergoing percutaneous coronary intervention， this agent is often not administered upstream (before angiography) as recommended by the American College of Cardiology/American Heart Association guidelines because of potential bleeding in the minority of patients who require CABG.
METHODS: The ACUITY trial enrolled 13，819 patients with NSTE-ACS undergoing early invasive management. The timing of clopidogrel initiation was per investigator discretion. A 5-day washout period before CABG was recommended for patients having received clopidogrel.
RESULTS: Of 13，819 patients enrolled， 1，539 (11.1%) underwent CABG before discharge. Clopidogrel-exposed patients had a longer median duration of hospitalization (12.0 days vs. 8.9 days， p < 0.0001)， but fewer adverse composite ischemic events (death， myocardial infarction， or unplanned revascularization) at 30 days; 12.7% vs. 17.3%， p = 0.01)， with nonsignificantly different rates of non-CABG-related major bleeding (3.4% vs. 3.2%， p = 0.87) and post-CABG major bleeding (50.3% vs. 50.9%， p = 0.83) compared with those patients not administered clopidogrel. By multivariable analysis， clopidogrel use before CABG was an independent predictor of reduced 30-day composite ischemia (odds ratio: 0.67， 95% confidence interval: 0.48 to 0.92， p = 0.001) but not of increased post-CABG major bleeding (odds ratio: 0.98， 95% confidence interval: 0.80 to 1.19， p = 0.80).
CONCLUSIONS: Clopidogrel administration before catheterization in patients with NSTE-ACS requiring CABG is associated with significantly fewer 30-day adverse ischemic events without significantly increasing major bleeding， compared to withholding clopidogrel until after angiography. These findings support the American College of Cardiology/American Heart Association guidelines for upstream clopidogrel administration in all NSTE-ACS patients， including those who subsequently undergo CABG.
目的：ACUITY（急性导管插入术和紧急介入治疗策略）研究旨在评估非ST段抬高急性冠脉综合征（NSTE-ACS）需要冠脉搭桥（CABG）的患者提前氯吡格雷治疗的作用。
背景： NSTE-ACS行经皮冠脉介入应用氯吡格雷使患者获益，尽管ACC/AHA指南推荐造影前使用氯吡格雷，但是在实际操作中经常不会提前使用，因为考虑到少数需要CABG的患者可能存在潜在出血的风险。
方法：ACUITY研究入选了13，819例NSTE-ACS早期侵入性治疗的患者。每个研究者慎重考虑了开始应用氯吡格雷的时机。推荐患者CABG前5天冲蚀期接受氯吡格雷治疗。
结果：入选的13，819例患者中，1，539例（11.1%）患者出院前行CABG。与未接受氯吡格雷治疗的患者相比，氯吡格雷治疗患者平均住院时间较长（12.0 d vs. 8.9 d， p < 0.0001），但是30天不良复合缺血事件（死亡、心梗或无计划的血管重建）发生率低（12.7% vs. 17.3%， p = 0.01）；非CABG相关的主要出血（3.4% vs. 3.2%， p = 0.87）和CABG后主要出血（50.3% vs. 50.9%， p = 0.83）无显著差异。
通过多变量分析，CABG前氯吡格雷治疗是减少30天复合缺血（比值比: 0.67， 95% 可信区间: 0.48 - 0.92， p = 0.001）的独立预测因子，但不是增加CABG后主要出血的（比值比: 0.98， 95% 可信区间: 0.80 - 1.19， p = 0.80）。
结论：与血管造影术后应用氯吡格雷相比，需要CABG的NSTE-ACS患者导管插入术前氯吡格雷治疗与减少30天不良缺血事件显著相关，而与主要出血增加无显著相关性。研究发现支持ACC/AHA指南中所有NSTE-ACS患者（包括继发行CABG的患者）提前氯吡格雷治疗的说法。