吳瑛　張曉星　田蕾　蔣娟娟　許莉　黃一玲　劉紅　李一石

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·臨床研究·

冠狀動(dòng)脈造影術(shù)與支架置入術(shù)對(duì)血小板聚集率影響的研究

吳瑛張曉星田蕾蔣娟娟許莉黃一玲劉紅李一石

目的探討冠狀動(dòng)脈造影與支架置入術(shù)對(duì)腺苷二磷酸(ADP)誘導(dǎo)的血小板聚集率的影響。方法前瞻性納入2012年5月1日至2013年4月30日中國(guó)醫(yī)學(xué)科學(xué)院阜外醫(yī)院冠心病患者343例，術(shù)前至少7 d連續(xù)服用阿司匹林100 mg，每日1次；氯吡格雷75 mg，每日1次。根據(jù)支架置入情況分為單純冠狀動(dòng)脈造影組(造影組，173例)和支架置入組(170例)?；颊咴诮邮芄跔顒?dòng)脈介入操作之前及之后24 h內(nèi)，分別采集空腹血樣本，用光學(xué)比濁法測(cè)定血小板聚集率，比較兩組患者術(shù)前、術(shù)后血小板聚集率的變化，支架置入組有66例患者自愿參加血小板聚集率復(fù)測(cè)亞組分析。結(jié)果 兩組患者術(shù)前、術(shù)后血小板聚集率比較，差異無(wú)統(tǒng)計(jì)學(xué)意義(P>0.05)；造影組患者術(shù)前、術(shù)后血小板聚集率比較，差異無(wú)統(tǒng)計(jì)學(xué)意義(P=0.062)，而支架置入組患者術(shù)后血小板聚集率顯著高于術(shù)前[(55.59±10.47)%比(52.47±11.97)%，P<0.001]，差異有統(tǒng)計(jì)學(xué)意義；支架置入組患者術(shù)后血小板聚集率增加大于造影組[(3.12±8.31)%比(1.06±7.40)%，P=0.010]，差異有統(tǒng)計(jì)學(xué)意義。隨著患者支架置入數(shù)量的增加，術(shù)后血小板聚集率呈遞增趨勢(shì)，但差異無(wú)統(tǒng)計(jì)學(xué)意義(P>0.05)。支架置入組血小板聚集率復(fù)測(cè)亞組患者(66例)術(shù)后30 d血小板聚集率顯著低于術(shù)后24 h[(54.71±11.64)%比(56.68 ±10.21)%，P=0.019]，且與術(shù)前基線值比較，差異無(wú)統(tǒng)計(jì)學(xué)意義[(54.71±11.64)%比(54.26± 12.23)%，P=0.901]。結(jié)論冠狀動(dòng)脈支架置入操作可導(dǎo)致術(shù)后血小板活性升高,該作用可在術(shù)后30 d內(nèi)消失,而單純冠狀動(dòng)脈造影則無(wú)此影響。

冠狀動(dòng)脈造影；支架置入術(shù)；血小板聚集

為降低冠狀動(dòng)脈粥樣硬化性心臟病(冠心病)患者支架內(nèi)血栓的發(fā)生率，臨床工作中逐步開(kāi)展了以測(cè)定個(gè)體血小板功能為依據(jù)，篩選出血小板高反應(yīng)性個(gè)體，給予在阿司匹林及氯吡格雷常規(guī)雙聯(lián)策略基礎(chǔ)上的長(zhǎng)期強(qiáng)化抗血小板藥物治療[1]。但已發(fā)表的研究結(jié)果并未顯示相應(yīng)的臨床獲益[2-3]。冠狀動(dòng)脈介入操作是否可導(dǎo)致一過(guò)性血小板活性升高，介入術(shù)后血小板功能的測(cè)定是否真實(shí)反映該個(gè)體長(zhǎng)期的血小板反應(yīng)性，這些尚無(wú)臨床研究證實(shí)。為此，有必要開(kāi)展冠心病患者冠狀動(dòng)脈造影與支架置入操作對(duì)血小板聚集率影響的研究，從而為規(guī)范圍術(shù)期抗血小板治療策略的個(gè)體化提供依據(jù)。

1　對(duì)象與方法

1.1研究對(duì)象

納入2012年5月1日至2013年4月30日在中國(guó)醫(yī)學(xué)科學(xué)院阜外醫(yī)院接受冠狀動(dòng)脈造影檢查的患者343例，根據(jù)血管病變情況行冠狀動(dòng)脈支架置入，并分為單純冠狀動(dòng)脈造影組(造影組，173例)和冠狀動(dòng)脈支架置入組(支架置入組，170例)。置入支架的適應(yīng)證由有經(jīng)驗(yàn)的術(shù)者遵循《中國(guó)經(jīng)皮冠狀動(dòng)脈介入治療指南2012(簡(jiǎn)本)》[4]，判定靶病變是否需要介入治療。

1.1.1入選標(biāo)準(zhǔn)(1)臨床診斷為冠心病，擬接受冠狀動(dòng)脈造影檢查，年齡18～85歲。(2)入院前已連續(xù)服用阿司匹林100 mg、每日1次，氯吡格雷75 mg、每日1次，連續(xù)服用≥7 d。

1.1.2排除標(biāo)準(zhǔn)(1)近14 d內(nèi)發(fā)生急性心肌梗死患者。(2)近14 d內(nèi)服用質(zhì)子泵抑制劑患者。(3)術(shù)前24 h內(nèi)及術(shù)后應(yīng)用血小板糖蛋白Ⅱb/Ⅲa抑制藥患者。(4)血小板計(jì)數(shù)小于100×109/L的患者。(5)術(shù)前或術(shù)后血小板聚集率檢測(cè)失敗患者。(6)伴有其他任何不適合行經(jīng)皮冠狀動(dòng)脈介入治療的疾病，包括嚴(yán)重腎功能不全、未控制的心功能不全、碘對(duì)比劑過(guò)敏等。(7)可能明顯改變研究藥物吸收、分布、代謝或排泄特征的任何手術(shù)或健康狀況：近12個(gè)月內(nèi)有活動(dòng)性炎癥性腸病病史，近3個(gè)月內(nèi)發(fā)生活動(dòng)性胃或十二指腸潰瘍，谷丙轉(zhuǎn)氨酶(GPT)或谷草轉(zhuǎn)氨酶(GOT)大于2倍正常值上限，肝性腦病病史，食管靜脈曲張病史，門(mén)靜脈分流史。

1.2臨床資料收集

收集患者基線資料，包括性別、年齡、體重指數(shù)(BMI)、高血壓病、2型糖尿病、高脂血癥、吸煙史等。實(shí)驗(yàn)室檢測(cè)血常規(guī)、凝血分析[(包括凝血酶原時(shí)間(PT)、活化部分凝血活酶時(shí)間(APTT)]、肝腎功能。

1.3血小板聚集率檢測(cè)

于患者接受冠狀動(dòng)脈介入操作前及之后的24 h內(nèi),分別采集空腹血樣本，應(yīng)用美國(guó)Chrono-Log公司560-CA型血小板聚集儀,以光學(xué)比濁法(LTA)進(jìn)行血小板聚集率測(cè)定。向富含血小板的血漿中加入5 μl預(yù)先配制好的10 μmol/L腺苷二磷酸(ADP)，然后放入儀器中進(jìn)行檢測(cè)。經(jīng)ADP激活后，血漿因血小板聚集，以其相對(duì)于貧血小板血漿透光度改善的最大值反映血小板聚集的百分比。測(cè)量曲線下降的最低點(diǎn)，即最大血小板聚集率。

1.4研究終點(diǎn)

研究主要終點(diǎn)是比較兩組患者介入操作后與操作前血小板聚集率的變化幅度；次要終點(diǎn)是比較兩種不同的介入操作方法對(duì)血小板聚集率的影響。將接受了冠狀動(dòng)脈支架置入的患者中自愿參加術(shù)后1個(gè)月血小板聚集率復(fù)測(cè)的患者進(jìn)行亞組分析，并在該組人群中對(duì)復(fù)測(cè)的血小板聚集率與支架置入術(shù)前及術(shù)后的測(cè)量值進(jìn)行比較。

1.5統(tǒng)計(jì)學(xué)分析

2　結(jié)果

符合入選標(biāo)準(zhǔn)的888例接受冠狀動(dòng)脈造影檢查的患者中，因接受負(fù)荷劑量氯吡格雷507例、接受單純冠狀動(dòng)脈球囊成形術(shù)7例、血小板聚集率檢測(cè)失敗7例、術(shù)后應(yīng)用血小板糖蛋白Ⅱb/Ⅲa抑制藥9例、未接受冠狀動(dòng)脈介入操作15例，共計(jì)545例未納入本研究。納入研究的343例患者中，170例(49.6%)因至少有一支冠狀動(dòng)脈主干狹窄大于70%而接受冠狀動(dòng)脈支架置入治療，平均置入支架(1.89±0.99)枚，其中66例(19.2%)患者術(shù)后30 d行血小板聚集率復(fù)測(cè)；173例(50.4%)僅行冠狀動(dòng)脈造影檢查，其中34例(9.9%)因嚴(yán)重冠狀動(dòng)脈病變建議行冠狀動(dòng)脈旁路移植術(shù)。2.1兩組患者基線資料情況比較

兩組患者年齡、性別、BMI、吸煙史、高血壓病、血小板計(jì)數(shù)、血紅蛋白濃度、血小板聚集率等比較，差異均無(wú)統(tǒng)計(jì)學(xué)意義(均P>0.05，表1)。

表1　兩組患者基線資料情況比較

圖1　兩組患者術(shù)前與術(shù)后的血小板聚集率比較

2.2兩組患者術(shù)后血小板聚集率情況

造影組與支架置入組術(shù)后血小板聚集率比較，差異無(wú)統(tǒng)計(jì)學(xué)意義[(54.21±11.44)%比(55.59±10.47)%，P=0.243]。造影組患者術(shù)前、術(shù)后血小板聚集率比較，差異無(wú)統(tǒng)計(jì)學(xué)意義(P=0.062)，而支架置入組患者術(shù)后血小板聚集率顯著高于術(shù)前[(55.59±10.47)%比(52.47±11.97)%，P<0.001]，差異有統(tǒng)計(jì)學(xué)意義(圖1)。根據(jù)支架置入數(shù)量進(jìn)一步分析顯示，隨支架置入數(shù)量的增加, 術(shù)后血小板聚集率呈增加趨勢(shì)，但差異均無(wú)統(tǒng)計(jì)學(xué)意義(均P>0.05，圖2)。支架置入組患者術(shù)后血小板聚集率增加大于造影組[(3.12±8.31)%比(1.06±7.40)%，P=0.010]，差異有統(tǒng)計(jì)學(xué)意義。根據(jù)血小板聚集率增加的幅度進(jìn)行分類(lèi)分析，支架置入組血小板聚集率增幅大于5%的患者比例顯著大于造影組(38.8%比24.9%，P=0.005，表2)。

圖2　置入不同數(shù)量支架患者術(shù)后的血小板聚集率比較

血小板聚集率增加值造影組(173例)支架置入組(170例)總患者(343例)P值≤067(38.7)58(34.1)125(36.4)0.3750～5%63(36.4)46(27.1)109(31.8)0.063>5%43(24.9)66(38.8)109(31.8)0.005

2.3術(shù)后30 d血小板聚集率復(fù)測(cè)

支架置入組患者均持續(xù)給予氯吡格雷75 mg，每日1次；阿司匹林100 mg，每日1次常規(guī)抗血小板治療。其中66例患者(38.8%)在術(shù)后30 d自愿參加血小板聚集率復(fù)測(cè)的亞組分析。結(jié)果顯示，在該亞組患者中，冠狀動(dòng)脈支架置入術(shù)后24 h內(nèi)血小板聚集率顯著高于術(shù)前基線[(56.68±10.21)%比(54.26±12.23)%，P=0.047]，術(shù)后30 d血小板聚集率顯著低于術(shù)后24 h[(54.71±11.64)%比(56.68 ±10.21)%，P=0.019]，且與術(shù)前基線值比較，差異無(wú)統(tǒng)計(jì)學(xué)意義[(54.71±11.64)%比(54.26± 12.23)%，P=0.901]。

3　討論

本研究通過(guò)不同時(shí)間對(duì)血小板聚集率檢測(cè)發(fā)現(xiàn)，不同冠狀動(dòng)脈介入操作類(lèi)型對(duì)血小板活性的影響存在差異。本研究結(jié)果顯示，冠狀動(dòng)脈支架置入組患者術(shù)后次日血小板聚集率顯著高于術(shù)前，且亞組分析顯示術(shù)后次日血小板聚集率亦顯著高于術(shù)后30 d，差異均有統(tǒng)計(jì)學(xué)意義；而單純冠狀動(dòng)脈造影組患者造影術(shù)前、造影術(shù)次日血小板聚集率比較，差異無(wú)統(tǒng)計(jì)學(xué)意義；與冠狀動(dòng)脈造影組相比，支架置入組患者術(shù)后血小板聚集率升高幅度更為顯著。該結(jié)果考慮與支架置入過(guò)程中，冠狀動(dòng)脈血管內(nèi)皮受到損傷，內(nèi)皮下膠原暴露，進(jìn)一步導(dǎo)致血小板激活、黏附、聚集和釋放有關(guān)[5-7]。

近年研究表明, 人群中存在的氯吡格雷反應(yīng)性差異表現(xiàn)為ADP誘導(dǎo)的血小板聚集率升高，且與主要不良心臟事件的發(fā)生相關(guān)[8-9]。指南中亦建議臨床醫(yī)師對(duì)特定的患者可以考慮根據(jù)血小板聚集率進(jìn)行個(gè)體化治療[1-2]。但在根據(jù)術(shù)后血小板功能檢測(cè)結(jié)果調(diào)整抗血小板治療策略的隨機(jī)分組研究中，僅觀察到了劑量調(diào)整組中血小板功能的進(jìn)一步抑制，未觀察到臨床預(yù)后的改善[3,10]。結(jié)合本研究結(jié)果考慮，可能是由于冠狀動(dòng)脈支架置入操作導(dǎo)致術(shù)后一過(guò)性升高的血小板活性未能真實(shí)體現(xiàn)個(gè)體對(duì)氯吡格雷的長(zhǎng)期反應(yīng)性。因此錯(cuò)誤地給予患者長(zhǎng)時(shí)間高強(qiáng)度的抗血小板治療,不僅不能改善患者預(yù)后，反而可能增加出血風(fēng)險(xiǎn)及額外的經(jīng)濟(jì)負(fù)擔(dān)[11]。

本研究分析顯示，隨著置入支架數(shù)量的增加，患者術(shù)后血小板聚集率呈上升趨勢(shì)，但差異并無(wú)統(tǒng)計(jì)學(xué)意義。這可能與血小板聚集率增幅低、患者樣本量小有關(guān)。有研究發(fā)現(xiàn)，支架置入術(shù)后24 h血小板活性顯著低于術(shù)后即刻[12]。本研究為避免檢測(cè)結(jié)果受飲食因素影響, 在支架置入術(shù)后24 h內(nèi)對(duì)患者空腹采血行血小板聚集率檢測(cè)而非術(shù)后即刻, 這也可能是組間差異無(wú)統(tǒng)計(jì)學(xué)意義的另一因素。

氯吡格雷聯(lián)合阿司匹林雙聯(lián)抗血小板治療是冠狀動(dòng)脈支架置入術(shù)后的標(biāo)準(zhǔn)治療[13]。早期的國(guó)外指南及我國(guó)指南對(duì)預(yù)計(jì)接受擇期冠狀動(dòng)脈介入治療操作術(shù)前6 h或更早，建議服用負(fù)荷劑量氯吡格雷300 mg[4,14-15]。Gurbel等[16-17]研究結(jié)果顯示，冠心病擇期支架置入術(shù)前頓服負(fù)荷劑量氯吡格雷300 mg對(duì)血小板的抑制作用小于75 mg連續(xù)每日服用。故而未服用過(guò)氯吡格雷的患者在接受300 mg負(fù)荷劑量后繼續(xù)接受75 mg、每日1次維持劑量治療，其持續(xù)下降的血小板聚集率不能準(zhǔn)確反映介入操作對(duì)血小板聚集率的影響。由此，本研究?jī)H分析術(shù)前未接受負(fù)荷劑量氯吡格雷且術(shù)后連續(xù)服用超過(guò)7 d的患者不同時(shí)間點(diǎn)的血小板聚集率，以期更準(zhǔn)確判斷介入操作過(guò)程對(duì)于血小板聚集率的直接影響。此外，提示臨床醫(yī)師針對(duì)擇期支架置入患者，術(shù)前采用連續(xù)口服氯吡格雷75 mg較頓服300 mg方案對(duì)血小板抑制作用更優(yōu)。

本研究是一項(xiàng)前瞻性觀察性研究，由于樣本量小及采血分析血小板聚集率的時(shí)間點(diǎn)有限，未能觀察到置入支架數(shù)量與血小板聚集率升高之間的明確聯(lián)系，亦未根據(jù)支架內(nèi)藥物涂層的類(lèi)型和支架長(zhǎng)度進(jìn)行亞組分析。今后可在更大樣本量的人群中根據(jù)支架置入數(shù)量、炎性因子及Micro-RNA等指標(biāo)進(jìn)一步地探索研究，以明確其間的相互聯(lián)系，為臨床治療策略提供進(jìn)一步理論依據(jù)。

總之，冠狀動(dòng)脈支架置入操作可導(dǎo)致術(shù)后血小板活性升高,該作用可在術(shù)后30 d內(nèi)消失,而單純冠狀動(dòng)脈造影則無(wú)此影響。本研究結(jié)果提示，基于冠狀動(dòng)脈支架置入術(shù)后測(cè)定的血小板聚集率作為判斷患者對(duì)血小板的長(zhǎng)期反應(yīng)性存在一定局限性。需綜合考慮患者置入支架數(shù)量、圍術(shù)期及長(zhǎng)期抗血小板藥物方案的耐受度等，以期最大限度改善冠心病患者預(yù)后。

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Impact of coronary angiography and stent implantation on platelet aggregation in coronary heart disease patients

WU Ying, ZHANG Xiao-xing, TIAN Lei, JIANG Juan-juan, XU Li, HUANG Yi-ling, LIU Hong, LI Yi-shi.

Key Laboratory of Clinical Trial Research in Cardiovascular Drugs, Ministry of Health, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100037, China Corresponding author: LIU Hong，Email：lchyl_fuwai@sina.com

ObjectiveTo evaluate the impact of coronary angiography and stent implantation procedure on ADP-induced platelet aggregation (PA) in coronary heart disease (CHD) patients. Methods CHD patients admitted in the Fuwai Hospital who had been treated with clopidogrel (75 mg/day) and aspirin (100 mg/day) for at least 7 consecutive days undergoing elective PCI were prospectively enrolled during May 1st2012 to April 30th2013. Based on whether coronary stent was implanted, all of the enrolled patients were divided into two groups: the coronary angiography (CAG) group and the coronary stent implantation (CSI) group. The differences in PA, measured by ADP induced light transmission aggregation， between the preoperative baseline level and the level at 24 hours after the procedures in both patient groups were determined. ResultsA total of 343 patients receiving coronary intervention were enrolled in this study, including 173 patients in the CAG group and 170 patients in the CSI group. Compared with the preoperative baseline, there was no significant difference in PA after the operation in the CAG group [(54.21±11.44)%vs. (53.15±11.80)%,P=0.062], while a significant postoperative PA increase was observed in the CSI group [(55.59±10.47)%vs. (52.47±11.97)%,P<0.001]. After stents implantation, PA showed an increased trend as the number of stents implanted increased. Compared with the CAG group, the PA increased in the CSI group was significantly greater [(3.12±8.31)%vs. (1.06±7.40)%，P=0.010]. Patients received repetitive PA testing (n=66) 30 days after coronary stent implantation, which is significantly lower than the PA 24 hours after PCI [(54.71±11.64)%vs. (56.68±10.21)%,P=0.019] and comparable with the baseline PA before procedure [(54.71±11.64)%vs. (54.26±12.23)%,P=0.901] in this subgroup. ConclusionsCoronary stent implantation causes a transient increase in ADP-induced PA, then returns to baseline after 30 days which does not happen in coronary angiography procedure alone.

Coronary angiography;Stent implantation;Platelet aggregation

10.3969/j.issn.1004-8812.2016.08.004

“重大新藥創(chuàng)制”科技重大專(zhuān)項(xiàng)(2012ZX09303-008-001)；2010年國(guó)家臨床重點(diǎn)專(zhuān)科建設(shè)項(xiàng)目(《衛(wèi)生部重點(diǎn)實(shí)驗(yàn)室項(xiàng)目》)

100037北京，衛(wèi)生部心血管藥物臨床研究重點(diǎn)實(shí)驗(yàn)室中國(guó)醫(yī)學(xué)科學(xué)院阜外醫(yī)院心內(nèi)科北京協(xié)和醫(yī)學(xué)院

劉紅，Email: lchyl_fuwai@sina.com

R541.4

2016-04-25)