冠狀旁路移植術患者術前服用氯吡格雷對于圍手術期影響的Meta分析_《中國循證醫學雜志》

作者：

馬軍 ,  徐維娟 , 徐桂萍

新疆烏魯木齊市友誼醫院麻醉科（烏魯木齊 830049）;

關鍵詞：

冠狀旁路移植術氯吡格雷系統評價 Meta分析隨機對照試驗

DOI：

10.7507/1672-2531.20130148

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目的　系統評價冠狀旁路移植術（coronary artery bypass grafting，CABG）患者術前服用氯吡格雷抗血小板治療對圍手術期的影響，為臨床指導此類患者合理用藥提供依據。
方法　計算機檢索PubMed、EMbase、Highwire、CENTRAL及其下屬各臨床注冊試驗數據中心、CBM、CNKI等數據庫。收集關于實施CABG患者術前使用氯吡格雷的隨機對照試驗（RCT）和非隨機的臨床對照試驗，檢索時限均為2003～2012年11月，并追溯納入研究的參考文獻。由兩名評價者按照納入和排除標準獨立篩選文獻，提取資料和評價質量后，采用RevMan 5.0軟件進行Meta分析。
結果　納入18個研究（10個RCT，8個非隨機的臨床對照試驗），共14 592例患者。Meta分析結果顯示：RCT的Meta分析結果顯示，CABG患者術前服用氯吡咯雷抗血小板與空白對照比較，能明顯降低術后心梗的發生率［RR=0.63，95%CI（0.48，0.83），P=0.000 9］，且兩組在術后24小時的出血量［MD=130，95%CI（–6.21，266.22），P=0.06］、因出血二次手術人數［RR=1.42，95%CI（0.92，2.20），P=0.12］和術后短期內的死亡風險增加[RR=1.19，95%CI（0.89，1.58)，P=0.24]方面差異無統計學意義。但非隨機的臨床對照試驗的Meta分析結果顯示，CABG患者術前服用氯吡咯雷抗血小板與空白對照比較，在降低術后心梗的發生率方面差異無統計學意義［RR=0.83，95%CI（0.30，2.26），P=0.71]，且氯吡咯雷組術后24小時的出血量［MD=82.42，95%CI（35.18，129.66)，P=0.000 6］、因出血二次手術人數［RR=1.71，95%CI（1.07，2.75），P=0.03］和術后短期內的死亡風險明顯增加［RR=1.89，95%CI（1.15，3.12），P=0.01］。
結論　目前證據顯示，CABG術前服用氯吡咯雷抗血小板治療能減少術后心梗的發生，但需謹慎考慮可能帶來的出血、二次開胸手術和術后短期內死亡風險的增加。RCT與非隨機的臨床對照試驗的結果存在矛盾，可能因納入研究的論證強度、數量及樣本量偏倚所致。上述結論需未來開展大規模高質量RCT結果予以證實。

引用本文： 馬軍,徐維娟,徐桂萍. 冠狀旁路移植術患者術前服用氯吡格雷對于圍手術期影響的Meta分析. 中國循證醫學雜志, 2013, 13(7): 827-835. doi: 10.7507/1672-2531.20130148 復制

1.	Eagle KA, Guyton RA, Davidoff R, et al. ACC/AHA 2004 guideline update for coronary artery bypass graft surgery:areportof the American College of Cardiology/American Heart Association Task Forceon Practice Guidelines(Committee toUpdate the1999 Guidelines for Coronary Artery Bypass Graft Surgery). Circulation, 2004, 110: e340-e437.
2.	Despotin GJ, Filos KS, Zoys TN, et al. Factors associated with excessive postoperative blood loss and hemostatic transfusion requirements: a multivariate analysis in cardiac surgical patients. Anesth Analg, 1996, 82(1): 13-21.
3.	Alghamdi AA, Moussa F, Fremes SE. Does the use of preoperative aspirin increase the risk of bleeding in patients undergoing coronary artery bypass grafting surgery? Systematic review and meta-analysis. J Card Surg, 2007, 22(3): 247-256.
4.	Gansera B, Schmidtler F, Spiliopoulos K. et al. Urgent or emergent coronary revascularization using bilateral internal thoracic artery after previous clopidogrel antiplatelet therapy. Thorac Cardiovasc Surg, 2003, 51(2): 185-189.
5.	Woo YJ, Grand T, Valettas N. Off-pump coronary artery bypass grafting attenuates postopera- tive bleeding associated with preoperative clopidogrel administration. Heart Surg Forum, 2003, 3(10): 282-285.
6.	Dempsey CM, Lim MS, Stacey SG. A prospective audit of blood loss and blood transfusion in patients undergoing coronary artery bypassgrafting after Clopidogrel and aspirintherapy. Crit Care Resusc, 2004, 6(5): 248-252.
7.	Karabulut H, Toraman F, Evrenkaya S, et al. Clopidogrel does not increase bleeding and allogen -ic blood transfusion in coronary artery surgery. Eur J Cardiothorac Surg, 2004, 25(3): 419-423.
8.	Chen L, Bracey AW, Radovancevic R, et al. Clopidogrel and bleeding in patients undergoing elective coronaryartery bypassgrafting. J Thorac Cardiovasc Surg, 2004, 128(7): 425-431.
9.	Nurozler F, KutluT, Kücük G, et al. Impact of clopidogrel on postoperative blood loss after non-elective coronary bypass surgery. Interact Cardiovasc Thorac Surg, 2005, 4(10): 546-549.
10.	Ascione R, Ghosh A, Rogers CA, et al. In-hospital patients exposed to clopidogrel before corona- ry artery bypass graft surgery: aword of caution. Ann Thorac Surg, 2005, 79(2): 1210-1216.
11.	Leong JY, Baker RA, Shah PJ, et al. Clopidogrel and bleed in gafter coronary artery bypass graft surgery. Ann Thorac Surg, 2005, 80(11): 928-933.
12.	Mehta RH, Roe MT, Mulgund J, et al. Acute clopidogrel use and outcomes in patients with non-ST-segment elevation acute coronary syndromes undergoing coronary artery bypass surgery. Jam CollCardiol, 2006, 48(7): 281-286.
13.	Kang W, Theman TE, Reed JF, et al. The effect of preoperative clopidogrel on bleeding after coronary artery bypass surgery. J Surg Educ, 2007, 64(10): 88-92.
14.	Filsou? F, Rahmanian PB, Castillo JG, et al.Clopidogrel treatment before coronary artery bypass graft surgery increases postoperative morbidity and blood product requirements. J Cardiothorac Vasc Anesth, 2008, 22(1): 60-66.
15.	Kim JH, Newby LK, Clare RM, et al. Clopidogrel use and bleeding after coronary artery bypass graft surgery. Am Heart J, 2008, 156(4): 886-892.
16.	Maltais S, Perrault LP, Do QB. Effect of clopidogrel on bleeding and transfusions after off- pump coronary artery bypass graft surgery: impact of discontinuation prior to surgery. Eur J Cardiothorac Surg, 2008, 34(5): 127-131.
17.	Ebrahimi R, Dyke C, Mehran R, et al. Outcomes following pre-operative clopidogrel administra -tion in patients with acute coronary syndromes undergoing coronaryartery bypass surgery: the ACUITY(Acute Catheterization and Urgent Intervention Triagestrateg Y)trial. J Am Coll Cardiol, 2009, 53(2): 1965-1972.
18.	Vaccarino GN, Thierer J, Albertal M, et al. Impact of preoperative clopidogrel in offpump coronary artery bypass surgery: apropensityscore analysis. J Thorac Cardiovasc Surg, 2009, 137(4): 309-313.
19.	Nesher N, Singh SK, Hosam F, et al. Impact of clopidogrel use on mortality and major bleeding in patients undergoing coronary artery bypass surgery. Interactive Cardio Vascular and Thoracic Surgery, 2010, 10(8): 732-736.
20.	Mengistu AM, Mayer J, Boldt J, et al. Usefulness of monitoring platelet function by multiple electrode aggregometry in primary coronary artery bypass surgery. J Cardiothorac Vasc Anesth, 2011, 25(3): 42-47.
21.	Hartmuth B. Bittner, Sven L, et al. Impact of clopidogrel on bleeding complications and survival in off-pump coronary artery bypass grafting. Interactive Cardio Vascular and Thoracic Surgery, 2012, 14(2): 273-278.
22.	Daly DJ, Myles PS, Smith JA, et al. Anticoagulation, bleeding and blood transfusion practices in Australasian cardiac surgical practice.Anaesth Intensive Care, 2007, 35(5): 760-768.
23.	王禹, 蓋魯粵, 沈洪, 等. 國產氯吡格雷在急性心肌梗死急診冠脈介人治療過程中的有效性及對血小板聚集功能的影響. 中國急救醫學, 2006, 26(7): 512-514.
24.	Ranucci M, Bozzetti G, Ditta A, et al. Surgical re-exploration after cardiac operations:why aworse outcome?. Ann ThoracSurg, 2008, 86(8): 1557-1562.
25.	馬海平, 鄭宏. 抗血小板治療冠狀旁路移植術圍術期抗纖溶治療效果的薈萃分析. 中華心血管病雜志, 2011, 39 (8): 759-763.

1. Eagle KA, Guyton RA, Davidoff R, et al. ACC/AHA 2004 guideline update for coronary artery bypass graft surgery:areportof the American College of Cardiology/American Heart Association Task Forceon Practice Guidelines(Committee toUpdate the1999 Guidelines for Coronary Artery Bypass Graft Surgery). Circulation, 2004, 110: e340-e437.
2. Despotin GJ, Filos KS, Zoys TN, et al. Factors associated with excessive postoperative blood loss and hemostatic transfusion requirements: a multivariate analysis in cardiac surgical patients. Anesth Analg, 1996, 82(1): 13-21.
3. Alghamdi AA, Moussa F, Fremes SE. Does the use of preoperative aspirin increase the risk of bleeding in patients undergoing coronary artery bypass grafting surgery? Systematic review and meta-analysis. J Card Surg, 2007, 22(3): 247-256.
4. Gansera B, Schmidtler F, Spiliopoulos K. et al. Urgent or emergent coronary revascularization using bilateral internal thoracic artery after previous clopidogrel antiplatelet therapy. Thorac Cardiovasc Surg, 2003, 51(2): 185-189.
5. Woo YJ, Grand T, Valettas N. Off-pump coronary artery bypass grafting attenuates postopera- tive bleeding associated with preoperative clopidogrel administration. Heart Surg Forum, 2003, 3(10): 282-285.
6. Dempsey CM, Lim MS, Stacey SG. A prospective audit of blood loss and blood transfusion in patients undergoing coronary artery bypassgrafting after Clopidogrel and aspirintherapy. Crit Care Resusc, 2004, 6(5): 248-252.
7. Karabulut H, Toraman F, Evrenkaya S, et al. Clopidogrel does not increase bleeding and allogen -ic blood transfusion in coronary artery surgery. Eur J Cardiothorac Surg, 2004, 25(3): 419-423.
8. Chen L, Bracey AW, Radovancevic R, et al. Clopidogrel and bleeding in patients undergoing elective coronaryartery bypassgrafting. J Thorac Cardiovasc Surg, 2004, 128(7): 425-431.
9. Nurozler F, KutluT, Kücük G, et al. Impact of clopidogrel on postoperative blood loss after non-elective coronary bypass surgery. Interact Cardiovasc Thorac Surg, 2005, 4(10): 546-549.
10. Ascione R, Ghosh A, Rogers CA, et al. In-hospital patients exposed to clopidogrel before corona- ry artery bypass graft surgery: aword of caution. Ann Thorac Surg, 2005, 79(2): 1210-1216.
11. Leong JY, Baker RA, Shah PJ, et al. Clopidogrel and bleed in gafter coronary artery bypass graft surgery. Ann Thorac Surg, 2005, 80(11): 928-933.
12. Mehta RH, Roe MT, Mulgund J, et al. Acute clopidogrel use and outcomes in patients with non-ST-segment elevation acute coronary syndromes undergoing coronary artery bypass surgery. Jam CollCardiol, 2006, 48(7): 281-286.
13. Kang W, Theman TE, Reed JF, et al. The effect of preoperative clopidogrel on bleeding after coronary artery bypass surgery. J Surg Educ, 2007, 64(10): 88-92.
14. Filsou? F, Rahmanian PB, Castillo JG, et al.Clopidogrel treatment before coronary artery bypass graft surgery increases postoperative morbidity and blood product requirements. J Cardiothorac Vasc Anesth, 2008, 22(1): 60-66.
15. Kim JH, Newby LK, Clare RM, et al. Clopidogrel use and bleeding after coronary artery bypass graft surgery. Am Heart J, 2008, 156(4): 886-892.
16. Maltais S, Perrault LP, Do QB. Effect of clopidogrel on bleeding and transfusions after off- pump coronary artery bypass graft surgery: impact of discontinuation prior to surgery. Eur J Cardiothorac Surg, 2008, 34(5): 127-131.
17. Ebrahimi R, Dyke C, Mehran R, et al. Outcomes following pre-operative clopidogrel administra -tion in patients with acute coronary syndromes undergoing coronaryartery bypass surgery: the ACUITY(Acute Catheterization and Urgent Intervention Triagestrateg Y)trial. J Am Coll Cardiol, 2009, 53(2): 1965-1972.
18. Vaccarino GN, Thierer J, Albertal M, et al. Impact of preoperative clopidogrel in offpump coronary artery bypass surgery: apropensityscore analysis. J Thorac Cardiovasc Surg, 2009, 137(4): 309-313.
19. Nesher N, Singh SK, Hosam F, et al. Impact of clopidogrel use on mortality and major bleeding in patients undergoing coronary artery bypass surgery. Interactive Cardio Vascular and Thoracic Surgery, 2010, 10(8): 732-736.
20. Mengistu AM, Mayer J, Boldt J, et al. Usefulness of monitoring platelet function by multiple electrode aggregometry in primary coronary artery bypass surgery. J Cardiothorac Vasc Anesth, 2011, 25(3): 42-47.
21. Hartmuth B. Bittner, Sven L, et al. Impact of clopidogrel on bleeding complications and survival in off-pump coronary artery bypass grafting. Interactive Cardio Vascular and Thoracic Surgery, 2012, 14(2): 273-278.
22. Daly DJ, Myles PS, Smith JA, et al. Anticoagulation, bleeding and blood transfusion practices in Australasian cardiac surgical practice.Anaesth Intensive Care, 2007, 35(5): 760-768.
23. 王禹, 蓋魯粵, 沈洪, 等. 國產氯吡格雷在急性心肌梗死急診冠脈介人治療過程中的有效性及對血小板聚集功能的影響. 中國急救醫學, 2006, 26(7): 512-514.
24. Ranucci M, Bozzetti G, Ditta A, et al. Surgical re-exploration after cardiac operations:why aworse outcome?. Ann ThoracSurg, 2008, 86(8): 1557-1562.
25. 馬海平, 鄭宏. 抗血小板治療冠狀旁路移植術圍術期抗纖溶治療效果的薈萃分析. 中華心血管病雜志, 2011, 39 (8): 759-763.

《中國循證醫學雜志》

冠狀旁路移植術患者術前服用氯吡格雷對于圍手術期影響的Meta分析

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《中國循證醫學雜志》

冠狀旁路移植術患者術前服用氯吡格雷對于圍手術期影響的Meta分析

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