冠状旁路移植术患者术前服用氯吡格雷对于围手术期影响的Meta分析_《中国循证医学杂志》

作者：

马军 ,  徐维娟 , 徐桂萍

新疆乌鲁木齐市友谊医院麻醉科（乌鲁木齐 830049）;

关键词：

冠状旁路移植术氯吡格雷系统评价 Meta分析随机对照试验

DOI：

10.7507/1672-2531.20130148

视频：

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摘要 全文 图表 视频 参考文献 施引文献 补充材料

目的　系统评价冠状旁路移植术（coronary artery bypass grafting，CABG）患者术前服用氯吡格雷抗血小板治疗对围手术期的影响，为临床指导此类患者合理用药提供依据。
方法　计算机检索PubMed、EMbase、Highwire、CENTRAL及其下属各临床注册试验数据中心、CBM、CNKI等数据库。收集关于实施CABG患者术前使用氯吡格雷的随机对照试验（RCT）和非随机的临床对照试验，检索时限均为2003～2012年11月，并追溯纳入研究的参考文献。由两名评价者按照纳入和排除标准独立筛选文献，提取资料和评价质量后，采用RevMan 5.0软件进行Meta分析。
结果　纳入18个研究（10个RCT，8个非随机的临床对照试验），共14 592例患者。Meta分析结果显示：RCT的Meta分析结果显示，CABG患者术前服用氯吡咯雷抗血小板与空白对照比较，能明显降低术后心梗的发生率［RR=0.63，95%CI（0.48，0.83），P=0.000 9］，且两组在术后24小时的出血量［MD=130，95%CI（–6.21，266.22），P=0.06］、因出血二次手术人数［RR=1.42，95%CI（0.92，2.20），P=0.12］和术后短期内的死亡风险增加[RR=1.19，95%CI（0.89，1.58)，P=0.24]方面差异无统计学意义。但非随机的临床对照试验的Meta分析结果显示，CABG患者术前服用氯吡咯雷抗血小板与空白对照比较，在降低术后心梗的发生率方面差异无统计学意义［RR=0.83，95%CI（0.30，2.26），P=0.71]，且氯吡咯雷组术后24小时的出血量［MD=82.42，95%CI（35.18，129.66)，P=0.000 6］、因出血二次手术人数［RR=1.71，95%CI（1.07，2.75），P=0.03］和术后短期内的死亡风险明显增加［RR=1.89，95%CI（1.15，3.12），P=0.01］。
结论　目前证据显示，CABG术前服用氯吡咯雷抗血小板治疗能减少术后心梗的发生，但需谨慎考虑可能带来的出血、二次开胸手术和术后短期内死亡风险的增加。RCT与非随机的临床对照试验的结果存在矛盾，可能因纳入研究的论证强度、数量及样本量偏倚所致。上述结论需未来开展大规模高质量RCT结果予以证实。

引用本文： 马军,徐维娟,徐桂萍. 冠状旁路移植术患者术前服用氯吡格雷对于围手术期影响的Meta分析. 中国循证医学杂志, 2013, 13(7): 827-835. doi: 10.7507/1672-2531.20130148 复制

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.	Filsouﬁ 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, 盖鲁粤, 沈洪, 等. 国产氯吡格雷在急性心肌梗死急诊冠脉介人治疗过程中的有效性及对血小板聚集功能的影响. 中国急救医学, 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.	马海平, 郑宏. 抗血小板治疗冠状旁路移植术围术期抗纤溶治疗效果的荟萃分析. 中华心血管病杂志, 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. Filsouﬁ 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, 盖鲁粤, 沈洪, 等. 国产氯吡格雷在急性心肌梗死急诊冠脉介人治疗过程中的有效性及对血小板聚集功能的影响. 中国急救医学, 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. 马海平, 郑宏. 抗血小板治疗冠状旁路移植术围术期抗纤溶治疗效果的荟萃分析. 中华心血管病杂志, 2011, 39 (8): 759-763.

《中国循证医学杂志》

冠状旁路移植术患者术前服用氯吡格雷对于围手术期影响的Meta分析

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《中国循证医学杂志》

冠状旁路移植术患者术前服用氯吡格雷对于围手术期影响的Meta分析

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