【作者】 黄琪；

【导师】 胡申江；

【作者基本信息】 浙江大学 ， 内科学， 2004， 硕士

【摘要】 一、研究背景 冠状动脉粥样硬化是引起缺血性心脏病最常见的病因，而冠状动脉粥样斑块破裂、血小板勃附并发血栓形成等又是诱发急性冠状动脉综合症(acute coronarysyndromes，ACs)的病理基础，目前用于治疗ACS的经皮冠状动脉介入治疗(percutaneous coron脚interventions，pCI)已在临床得到广泛应用，其围手术期常规使用抗血小板活性(阿司匹林、嚷氯匹咙)及抗凝(低分子肝素)药物来防止术中及术后的血栓形成，但在上述药物使用后是否会导致血小板活性及凝血功能的改变尚不确定。在本研究中我们选用血浆血小板膜糖蛋白140(plateletalpha一granule membrane glyeoprotein 140，GMp一140)、纤维蛋白肤A(fibrinopeptideA，F队)及凝血酶原时间(prothlombin time，PT)来观察ACS患者上述指标的改变以及在PCI围手术期常规抗血小板活性及抗凝药物使用后该指标的变化。 二、研究方法 研究对象:2002年6月至2003年3月期间在浙江大学医学院附属第一医院心血管内科住院行经皮冠状动脉腔内成形术及支架植入术(percutancoustransluminal eoronary angioplasty ands李ent imp]antation，pTCA+stent)的32例ACs患者，并分为不稳定心绞痛(unstable angina peetoris，UAp)组(n一17)和急性心肌梗死(acute myoeardial infaretion，AMx)组(n一15)，将同期住院行冠状动脉造影结果阴性的患者作为对照。均除外患有肝肾疾病、急性感染、免疫性疾病、脑血管病、肿瘤、凝血纤溶障碍、未控制的高血压患者以及由于其它疾病正在使用研究中的任何一种抑制血小板聚集或抗凝药物者。 方法:所有病例在入院后均给予常规扩血管(硝酸酷类药物)和抗血小板活性浙江大学硕士论文及抗凝治疗【阿司匹林300mg口服，每天一次，抵克力得250mg口服，每天两次，使用3天后手术治疗;术后阿司匹林及抵克力得继续口服，加用低分子肝素(商品名:速碧林)0.4ml皮下注射，每天两次』;PTcA+stent术采用经股动脉穿刺插管，参照标准方法进行操作。所有患者在入院次晨空腹从肘静脉取血，ACS患者在术后第3天清晨再次空腹取血测定FPA、GMP一140及PT值。 统计分析:计量资料以均数士标准差表示，采用SAS6.12统计软件进行t检验，单因素方差分析及直线相关分析。结果尸<0.05为有统计学差异。 三、研究结果 1.不稳定心绞痛组、急性心肌梗死组与对照组间血脂、血糖及血小板水平比较无明显差异(均尸>0 .05)。 2.入院时，ACS患者的F队及GMp一140水平较对照组者均明显升高(均P(0.05)，而PT水平无明显差异(P)0.05)。 3.术后第3天(用药6天后)，ACS患者FPA水平与入院时相比有明显下降(P<0 .05)，其水平与对照组患者无明显差异(尸>0 .05);术后第3天的GMP一140及PT水平与入院时无明显改变(均尸>0 .05)，其中GMP一1 40水平仍明显高于对照组患者(P<0.05)。 4.无论是入院时还是术后第3天，ACS患者中的UAP患者与AMI患者间F队、GMP一1 40及PT水平比较均无明显差异(均尸>0 .05)，而两者的FPA水平在术后第3天均比入院时有明显降低(尸<0.05)，其GMP一140及PT水平无明显改变(均尸>0 .05)。 5.ACS患者及对照组患者的FPA与GMP一140均无显著相关性(均尸>0 .05)。 四、结论 1.急性冠脉综合症患者体内的凝血功能及血小板活性较对照组明显增强。 2.急性冠脉综合症患者在PCI术围手术期常规抗血小板及抗凝治疗基础上，术后凝血活性得到明显抑制，而血小板活性指标没有明显改变。更多还原

【Abstract】 Backgrounds and PurposesAtherosclerosis is the most common cause of coronary heart disease, and the splitting of atheromatous plaque, dissections and fibrous tissue rupture, the abrasion of the endothelium and the rupture of the plaque expose fatty plaque (which contains tissue factor), all of which can induce activation of the platelets and coagulation, these are the pathology of acute coronary syndromes (ACS). Percutaneous transluminal coronary angioplasty and stent implantation (PTC A+Stent) is one of the percutaneous coronary interventions (PCI) ways treated ACS, and it has almost replaced the operation on ACS patients, because it is safer, more effective, less traumatic, and is repeatable compared with coronary artery bypass grafting (CABG). However, acute and subacute thrombuses of the vessel threaten the success of the procedure, so the antiplatelet and anticoagulant drugs are used to prevent the formation of acute and subacute thrombuses. But till now, the changes of platelet and coagulation activation after PTCA+Stent with the use of antiplatelet and anticoagulant drugs didn’t know. The aim of this study is to measure the plasma platelet alpha- granule membrane glycoprotein 140 (GMP-140), fibrinopeptide A (FPA) and prothrombin time (PT) in ACS patients when they were admitted and 3 days after PCI, and observe their/changes with using aspirin, ticlopidine and low molecular weight heparin (LMWH) conventionally.Methods32 consecutive ACS patients who underwent PTCA+Stent were enrolled in this study, and patients with history of bleeding peptic ulcer, known intolerance for any one of the studied drugs, treatment with drugs influencing the haemostatic system, concomitant malignant disease, acute infection, diseases in liver or kidney, brain vessels diseases and immunity system diseases were excluded. All patients were divided into 2 groups-acute myocardial infarction (AMI) group (n=15) and unstable angina pectoris (UAP) group (n=17) according to the cause of disease. 15 patients with normal angiocardiograph (CAG) results in the control group, the diagnosises were hypertension (3 cases), chronic gastritis (1 case), arrhythmia (1 case), gastroesophageal reflex disease (5 cases) or hypertrophic cardiomyopathy (3 cases).Additionally, conventional therapy including nitrates or 3 -blockers were continued without any changes. All the patients received aspirin 300mg/day and ticlopidine 500mg/day for 3 days before PCI, then aspirin and ticlopidine were orally taken continuously with LMWH 0.25ml hyodermicly twice a day after PCI. The way of PTCA+Stent was standard.Blood for the measurement of platelet activation (GMP-140) and coagulation function (FPA, PT) were collected at 5 AM from peripheral vein in order to avoiding the possible influence of circadian variation on the indexes.Immediately after collection the blood was placed in three plastic tubes, one containing 0.3ml of EDTA anticoagulant used for GMP-140 measurements was centrifuged at 1500r/min for 10 min; one containing 0.3ml of FPA anticoagulant used for FPA measurements was centrifuged at 3000r/min for 10 min and then treated with bentonite to remove fibrinogen; the last one containing 0.3ml of natrium citricum anticoagulant for PT was centrifuged at 3000r/min for 5 min, and all samples were stored at -70C until the assay. The plasma levels of FPA, GMP-140 were measured by a commercially available enzyme-linked immunosorbent assay (ELISA) kit, andClauss method was used for PT.The results were expressed as mean standard deviation (SD) and data from ACS patients were analyzed by Student’s t-test. Linear correlation analysis was used to determine the correlation between FPA and GMP-140. Statistical analysis were performed using a SAS6.12 package. P values less than 0.05 were considered statistically significant.Results1. There were no significant difference in blood lipid, blood glucose and blood platelet among the UAP group, AMI group and control group (P>0.05) .2. When the patients were admitted, the levels of F更多还原