2010循环杂志残余血小板活性预测心血管风险(5)

240

1.0

CirculationJanuary20,2009

No RPR (PRU <240)

1.00

RPR (PRU ≥240)

0.8

CV death-freeSurvival

0.98

SENSITIVITY

0.5

0.96

0.94

0.3

log-rank test p=0.02

0.92

2

4

6

8

10

12

0.0

0.0

0.3

0.5 0.8

1.0

Time (months)

1-SPECIFICITY

Figure1.Receiver-operatingcharacteristiccurvefortheVeri-fyNowP2Y12assay.

Figure2.Survivalfreefromcardiovascular(CV)deathinpatientswithandwithoutPRU 240.

Discussion

Inthisprospectivestudyofalargenumberofpatientsundergoingdual-antiplatelettherapy,wefoundthatRPRtoADPmeasuredbyapoint-of-careassaywasanindependentpredictorofcardiovasculardeathandnonfatalMIat12-monthfollow-upinpatientswithACSwhounderwentPCI.Thecutoffvaluefortheidentificationofpatientsathigherriskforischemiceventswas240PRU.Thisvalueisconsis-tentwiththatrevealedbythestudyofPriceetal,basedon380patients,8andbytheARMYDA-PRO(Antiplateletther-apyforReductionofMYocardialDamageduringAngioplasty-PlateletReactivityPredictsOutcome)study,10publishedduringtherevisionofthisreportandbasedon160patients.Thehighnegativepredictivevalue(96%)suggeststhatpatientswithPRUvalues 240canbelabeledasbeingatlowriskofrecurrences,whereasbecauseofthelowpositivepredictivevalue(12%),PRUvalues 240includepatientswhowillnotexperienceanischemicevent.

Inthepresentstudy,aswellasinthestudybyPriceetal,8thepredictiveaccuracyoftheVerifyNowassayintheidentificationofhigh-riskpatientswasmoderate(69%).

Table3.AreaUndertheReceiverOperatingCharacteristicCurveofDifferentRegressionModelsfortheDetectionofCardiovascularDeathandNonfatalMIat12-MonthFollow-Up

AUC(95%CI)

Model1:Classiccardiovascularriskfactors*Model2:Model1 proceduralriskfactors Model3:Model2 residualplateletreactivity

0.67(0.58–0.77)0.71(0.62–0.80)0.79(0.72–0.86)

TheadditionofRPRaccordingtoVerifyNowP2Y12totheclassicandproceduralcardiovascularriskfactorsmoderatelybutsignificantlyenhancedthepredictiveabilitytodefinetheriskofrecurrences.Inarecentstudy,11ahigher(95%)predictiveaccuracyofaplateletaggregationtestforischemiceventswasobtainedwhenplateletfunctionwasassessedbyarachidonicacidandcollageninadditiontoADPstimulation,whichemphasizesthatasinglepathwayassessmentdoesnotencompassthecomplexityoftheplateletroleinthromboticevents.Currently,anumberofassaysforplateletreactivitybydifferentmethodsandagonistsareunderlaboratoryandclinicalevaluation.12,13Amongthese,aflow-cytometricvasodilator-stimulatedphosphoproteinphosphorylationassaywasabletodetectareducedresponsetoclopidogrel14,15andtosuccessfullydrivetheantiplatelettherapyin162patientsundergoingPCI.16

WeareawarethatplateletreactivityatthetimeofACSmaybeinfluencedbyanumberofclinicalandlaboratory

No RPR (PRU <240)RPR (PRU ≥240)

1.00

Non-fatalMI-freeSurvival

0.98

0.96

0.94

log-rank test p=0.01

0.92

2

4

6

8

10

12

AUCindicatesareaunderthecurve.

P 0.004,model3vsmodel1;P 0.021,model3vsmodel2.

*Age,sex,hypertension,diabetes,dyslipidemia,smokinghabit,andrenalfailure.

Typeofstent,bifurcationlesion,totallengthofstent,No.ofvesselstreated,No.ofstentsimplanted,useofglycoproteinIIb/IIIainhibitors.

Time (months)

Figure3.SurvivalfreefromnonfatalMIinpatientswithandwithoutPRU 240.