目的:探讨急性缺血性卒中(Ischemic Stroke, IS)患者CYP2C19*2基因多态性与早期神经功能恶化(Early neurological deterioration, END)及抗血小板治疗预防END的相关性。方法:连续纳入570例急性IS患者随机分配到阿司匹林加氯吡格雷组(双抗组,284例)或阿司匹林组(单抗组,286例)。检测治疗前和治疗后7~10天血小板聚集率和血小板–白细胞聚集率,采用质谱法检测CYP2C19*2 (rs4244285)基因型。原发终点为入院10天内END。结果:121例(21.2%)发生END。CYP2C19*2功能降低等位基因与END高发生率相关(携带者为26.8%,非携带者为16.6%,P = 0.004)。双抗组END发生率低于单抗组(17.6%:24.8%,P = 0.032)。分层分析显示,对于CYP2C19*2功能降低等位基因携带者,双抗治疗比单抗治疗更有效降低END(18.8%:34.9%,P = 0.006)。对于非携带者,双抗治疗组和单抗治疗组之间END发生率无显著差异(16.7%:16.6%,P = 0.998)。结论:阿司匹林加氯吡格雷治疗可降低携带CYP2C19*2功能降低等位基因IS患者END发生率。 Objectives: The aim of this study was to investigate the association between CYP2C19*2 variants and early neurological deterioration (END), and the effectiveness of antiplatelet therapy for preven-tion of END according to CYP2C19*2 genotypes in patients with ischemic stroke (IS). Methods: 570 IS patients were randomly assigned to clopidogrel plus aspirin group (n = 284) or aspirin alone group (n = 286). Platelet aggregation and platelet-leukocyte aggregates were measured before and after 7~10 days of treatment. CYP2C19*2 (rs4244285) genotypes were examined using mass spec-trometry. The primary outcome was END during the 10 days of admission. Results: Among the 570 patients, 121 (21.2%) patients suffered from END. Carriers of CYP2C19*2 reduced-function alleles were associated with higher incidence of END (26.8% in carriers vs. 16.6% in noncarriers, P = 0.004). The incidence of END was lower in the clopidogrel plus aspirin group than in the aspirin alone group (17.6 vs. 24.8%, P = 0.032). Stratified analyses revealed that clopidogrel plus aspirin could be more effective in reducing END than aspirin alone for carriers of CYP2C19*2 re-duced-function alleles (18.8 vs. 34.9%, P = 0.006). However, there was no significant difference in incidence of END between dual therapy group and monotherapy group for noncarriers (16.7 vs. 16.6%, P = 0.998). Conclusions: Dual therapy with clopidogrel and aspirin may be adequate for prevention of END in carriers of CYP2C19*2 reduced-function alleles, but not for noncarriers.
目的:探讨急性缺血性卒中(Ischemic Stroke, IS)患者CYP2C19*2基因多态性与早期神经功能恶化(Early neurological deterioration, END)及抗血小板治疗预防END的相关性。方法:连续纳入570例急性IS患者随机分配到阿司匹林加氯吡格雷组(双抗组,284例)或阿司匹林组(单抗组,286例)。检测治疗前和治疗后7~10天血小板聚集率和血小板–白细胞聚集率,采用质谱法检测CYP2C19*2 (rs4244285)基因型。原发终点为入院10天内END。结果:121例(21.2%)发生END。CYP2C19*2功能降低等位基因与END高发生率相关(携带者为26.8%,非携带者为16.6%,P = 0.004)。双抗组END发生率低于单抗组(17.6%:24.8%,P = 0.032)。分层分析显示,对于CYP2C19*2功能降低等位基因携带者,双抗治疗比单抗治疗更有效降低END(18.8%:34.9%,P = 0.006)。对于非携带者,双抗治疗组和单抗治疗组之间END发生率无显著差异(16.7%:16.6%,P = 0.998)。结论:阿司匹林加氯吡格雷治疗可降低携带CYP2C19*2功能降低等位基因IS患者END发生率。
早期神经功能恶化,缺血性卒中,氯吡格雷,CYP2C19*2基因多态性,双联抗血小板治疗
Tao Zeng1, Chun Wang2*, Xingyang Yi2, Xiaoming Wang1, Ting Qing2, Qiang Zhou3, Jing Lin3
1Affiliated Hospital of North Sichuan Medical College, Nanchong Sichuan
2Department of Neurology, People’s Hospital of Deyang City, Deyang Sichuan
3Department of Neurology, The Third Affiliated Hospital of Wenzhou Medical University, Wenzhou Zhejiang
Received: Apr. 18th, 2021; accepted: May 18th, 2021; published: May 26th, 2021
Objectives: The aim of this study was to investigate the association between CYP2C19*2 variants and early neurological deterioration (END), and the effectiveness of antiplatelet therapy for prevention of END according to CYP2C19*2 genotypes in patients with ischemic stroke (IS). Methods: 570 IS patients were randomly assigned to clopidogrel plus aspirin group (n = 284) or aspirin alone group (n = 286). Platelet aggregation and platelet-leukocyte aggregates were measured before and after 7~10 days of treatment. CYP2C19*2 (rs4244285) genotypes were examined using mass spectrometry. The primary outcome was END during the 10 days of admission. Results: Among the 570 patients, 121 (21.2%) patients suffered from END. Carriers of CYP2C19*2 reduced-function alleles were associated with higher incidence of END (26.8% in carriers vs. 16.6% in noncarriers, P = 0.004). The incidence of END was lower in the clopidogrel plus aspirin group than in the aspirin alone group (17.6 vs. 24.8%, P = 0.032). Stratified analyses revealed that clopidogrel plus aspirin could be more effective in reducing END than aspirin alone for carriers of CYP2C19*2 reduced-function alleles (18.8 vs. 34.9%, P = 0.006). However, there was no significant difference in incidence of END between dual therapy group and monotherapy group for noncarriers (16.7 vs. 16.6%, P = 0.998). Conclusions: Dual therapy with clopidogrel and aspirin may be adequate for prevention of END in carriers of CYP2C19*2 reduced-function alleles, but not for noncarriers.
Keywords:Early Neurological Deterioration, Ischemic Stroke, Clopidogrel, CYP2C19*2 Gene Polymorphism, Dual Antiplatelet Therapy
Copyright © 2021 by author(s) and Hans Publishers Inc.
This work is licensed under the Creative Commons Attribution International License (CC BY 4.0).
http://creativecommons.org/licenses/by/4.0/
早期神经功能恶化(Early neurological deterioration, END)在急性缺血性卒中(ischemic stroke, IS)患者中发生率高,并与死亡率和功能预后密切相关 [
为2009年8月至2011年12月首次发病、NIHSS评分 < 15分、发病48小时内入住温州医科大学第三附属医院和德阳市人民医院、新TOAST分型为动脉粥样硬化型脑梗死患者。具体纳入标准和排除标准参见我们之前的文献描述 [
1) 资料收集:对于每个患者,入院时及入院后10天内每天由经过标准化培训的临床医师使用美国国立卫生研究院的卒中量表(National Institutes of Health Stroke Scale,NIHSS)对患者进行评分 [
2) CYP2C19*2单核苷酸多态性(SNPs)检测:用质谱法检测CYP2C19*2基因型 [
3) 血小板活化指标检测:入院时和治疗7~10天后,使用FC 500 MPC流式细胞仪直接荧光标记测量血小板–白细胞聚集率(Beckman Coulter Ltd., Krefeld, Germany)。用光学比浊法测定血小板聚集率。具体检测程序和方法参见我们以前文献描述 [
1) 原发终点:END,END定义为入院后10天内NIHSS评分增加 ≥ 2分,排除出血转化、另一血管区域的新梗塞、颅内出血(ICH)、低血压、低血糖、心脏并发症、发热或感染所致的加重 [
2) 次要终点:入院后10天内新发心肌梗塞、新发脑梗死和因心血管事件死亡等。
3) 安全终点:入院后10天内发生的颅内外出血事件。
终点事件采用盲法评估,即评估者对分组和CYP2C19*2 SNPs的结果不知情。
采用SPSS 16.0统计软件进行统计分析,单抗和双抗治疗组之间、有无END患者之间基线特征的差异采用单变量方法分析,计数资料用百分比表示,组间比较采用χ2检验;连续变量用 x ¯ ± s 表示,组间比较的正态分布资料用t检验,否则使用秩和检验。
根据单抗和双抗治疗组患者的基因型对END的生存分析用Kaplan-Meier曲线表述。采用Cox比例风险模型评价单抗和双抗治疗组CYP2C19*2基因型对END的影响。进入Cox模型以调整的协变量有:1) 单因素分析中,两组比较P < 0.2的变量;2) 传统卒中危险因素。Cox比例风险模型的结果用风险比(hazard ratio, HR)和95%CI (置信区间)表示。所有检验均为双侧分析,P值 < 0.05具有统计学意义。
121例(21.2%)患者发生END,其中78.5%的患者(95/121)发生在入院后48小时内,NIHSS评分增加的中位数(四分位距)为4 (2~8)。16例(2.8%)出现次要终点事件:10例新发梗死,2例死亡,4例心肌梗塞。21例(3.7%)出现安全终点事件:15例无症状性出血转化,1例无症状性脑出血,5例颅外出血。与未发生END的患者相比,发生END患者年龄更大、糖尿病比例高、入院时血小板聚集率和血小板白细胞聚集率更高(表1)。双抗治疗组50例(17.6%)患者发生END,单抗治疗组71例(24.8%)患者发生END。双抗治疗组的END发生率低于单抗治疗组(P = 0.032,表2)。
END患者(n = 121) | 无END的患者(n = 449) | P值 | |
---|---|---|---|
年龄(岁) | 70.9 ± 11.6 | 67.8 ± 15.2 | 0.015 |
男性(n,%) | 69 (57.0) | 244 (54.3) | 0.624 |
高血压(n,%) | 89 (73.6) | 325 (72.4) | 0.798 |
糖尿病(n,%) | 58 (47.9) | 157 (34.9) | 0.008 |
入院时NIHSS评分 | 11.3 ± 4.2 | 11.5 ± 4.4 | 0.651 |
高脂血症(n,%) | 87 (71.9) | 321 (71.5) | 0.998 |
院内治疗(n,%) | |||
溶栓 | 2 (1.7) | 9 (2.0) | 0.998 |
降血压药物 | 96 (79.3) | 365 (81.3) | 0.435 |
降血糖药物 | 60 (49.6) | 183 (40.8) | 0.089 |
他汀类药物 | 119 (98.3) | 442 (98.4) | 0.996 |
阿司匹林 | 71 (57.9) | 215 (48.1) | 0.032 |
阿司匹林加氯吡格雷 | 50 (42.1) | 234 (51.9) | 0.032 |
CYP2C19*2 | |||
GG | 52 (42.9) | 261 (58.1) | 0.004 |
AG + AA | 69 (57.0) | 188 (41.9) | 0.004 |
入院时血小板聚集率(%) | |||
AA诱导的血小板聚集率 | 90.8 ± 12.8 | 85.5 ± 18.7 | <0.001 |
ADP诱导的血小板聚集率 | 89.7 ± 13.4 | 84.6 ± 15.5 | <0.001 |
入院时血小板–白细胞聚集(%) | |||
白细胞 | 25.8 ± 5.2 | 22.5 ± 4.8 | <0.001 |
中性粒细胞 | 23.6 ± 5.7 | 21.3 ± 4.3 | <0.001 |
单核细胞 | 32.2 ± 6.8 | 27.7 ± 7.1 | <0.001 |
淋巴细胞 | 25.4 ± 5.9 | 23.2 ± 5.2 | <0.001 |
表1. 有或无END患者的基线特征及血小板聚集率比较
注:END,早期神经功能恶化;NIHSS,美国国立卫生研究院卒中量表;AA,花生四烯酸;ADP,腺苷酸5’-二磷酸。
CYP2C19*2基因型频率分布符合Hardy-Weinberg平衡(P > 0.05)。单抗和双抗治疗组CYP2C19*2基因型分布比较无统计学意义(表2)。携带CYP2C19*2 AG/AA (功能降低等位基因)和携带CYP2C19*2 GG (野生型)的患者,END发生率分别为26.8% (69/257)和16.6% (52/313) (P = 0.004,表1),两组间次要终点和安全终点无显著性差异(P > 0.05,表3)。无论是双抗治疗组还是单抗治疗组,CYP2C19*2功能降低等位基因携带者的血小板聚集率和血小板–白细胞聚集率均显著高于非携带者(表3)。
单抗疗法(n = 286) | 双抗治疗(n = 284) | P值 | |
---|---|---|---|
早期神经系统恶化(n,%) | 71 (24.8) | 50 (17.6) | 0.032 |
新发脑梗死(n,%) | 5 (1.7) | 5 (1.8) | 0.997 |
心肌梗死(n,%) | 2 (0.7) | 2 (0.7) | 0.999 |
死亡(n,%) | 1 (0.3) | 1 (0.4) | 0.998 |
安全终点 | |||
无症状HT (n,%) | 7 (2.4) | 8 (2.8) | 0.786 |
无症状ICH (n,%) | 0 (0.0) | 1 (0.4) | 0.297 |
颅外出血(n,%) | 2 (0.7) | 3 (1.1) | 0.677 |
CYP2C19*2 (n,%) | |||
GG | 157 (54.9) | 156 (54.9) | 0.999 |
AG + AA | 129 (45.1) | 128 (45.1) | 0.999 |
表2. 双抗治疗组和单抗治疗组患者的终点事件和CYP2C19*2基因型分布
注:HT,出血转化;ICH,颅内出血。
单抗 | 双抗 | |||
---|---|---|---|---|
CYP2C19*2 GG (n = 157) | CYP2C19*2 AG/AA (n = 129) | CYP2C19*2 GG (n = 156) | CYP2C19*2 AG/AA (n = 128) | |
END(n,%) | 26 (16.6) | 45 (34.9) | 26 (16.7) | 24 (18.8) |
AA诱导的血小板聚集(%) | ||||
入院时 | 85.6 ± 14.4 | 92.8 ± 15.3 | 84.9 ± 13.2 | 92.3 ± 11.9 |
7~10天时 | 21.3 ± 9.6 | 33.7 ± 9.5 | 20.9 ± 7.6 | 24.2 ± 8.6 |
ADP诱导的血小板聚集(%) | ||||
入院时 | 86.3 ± 13.7 | 93.4 ± 14.7 | 85.8 ± 14.6 | 93.8 ± 12.5 |
7~10天后 | 51.7 ± 11.4 | 72.5 ± 14.6 | 50.9 ± 15.3 | 58.7 ± 10.8 |
血小板–白细胞聚集(%) | ||||
入院时白细胞 | 22.3 ± 4.3 | 26.8 ± 4.1 | 22.7 ± 3.9 | 27.1 ± 4.7 |
7~10天后白细胞 | 16.1 ± 4.8 | 23.7 ± 4.5 | 15.7 ± 5.3 | 16.8 ± 6.2 |
入院时中性粒细胞 | 23.1 ± 3.9 | 27.1 ± 4.4 | 23.5 ± 4.2 | 27.3 ± 4.5 |
7~10天后的中性粒细胞 | 17.2 ± 4.3 | 23.8 ± 4.3 | 17.8 ± 5.6 | 18.6 ± 6.1 |
入院时单核细胞 | 28.7 ± 6.2 | 35.5 ± 7.7 | 29.1 ± 7.2 | 33.8 ± 7.4 |
7~10天后单核细胞 | 21.4 ± 4.9 | 31.7 ± 6.7 | 20.9 ± 5.4 | 23.9 ± 6.6 |
入院时淋巴细胞 | 22.6 ± 5.1 | 28.2 ± 6.2 | 22.4 ± 3.7 | 28.5 ± 5.6 |
7~10天后淋巴细胞 | 19.3 ± 6.9 | 26.1 ± 5.3 | 18.9 ± 7.3 | 22.5 ± 5.5 |
表3. CYP2C19*2基因型对单抗和双抗治疗组END和血小板活化的影响
注:END,早期神经功能恶化;AA,花生四烯酸;ADP,二磷酸腺苷采用t检验,与单抗组CYP2C19*2 AG/AA患者相比,P < 0.05。
分层分析显示,非功能降低等位基因携带者双抗和单抗治疗组之间的END发生率没有显著差异[16.7% (26/156)比16.6% (26/157),P = 0.998] (表3),入院时或治疗7~10天后,两组间血小板聚集率和血小板–白细胞聚集率也没有显着差异(均P > 0.05,表3);功能降低等位基因携带者双抗治疗组END发生率明显低于单抗治疗组[18.8% (24/128)比34.9% (45/129),P = 0.006) (表3),两组患者入院时血小板聚集率和血小板–白细胞聚集率无显著差异,但双抗治疗组在治疗7~10天后血小板聚集率和血小板–白细胞聚集率显著低于单抗治疗组(均P < 0.05,表3),提示对于CYP2C19*2功能降低等位基因携带者,阿司匹林联合氯吡格雷治疗比单用阿司匹林更能有效地减少END和抑制血小板活化。
Cox比例风险模型显示,在校正协变量后,双抗治疗与携带至少一个CYP2C19*2功能降低等位基因IS患者的END低风险独立相关(HR:0.78;95%CI:0.58~0.96;P = 0.013) (图1(A);表4),但不影响非携带者的END风险(HR:1.01;95%CI:0.83~2.03;P = 0.532) (图1(B);表4)。
图1. (A) 携带CYP2C19*2功能降低等位基因者抗血小板治疗相关终点累积自由度的Kaplan-Meier分析;(B) 非携带者抗血小板治疗相关终点累积自由度的Kaplan-Meier分析。END,早期神经功能恶化;HR,危险比;CI,置信区间
HR | 95%CI | P值 | |
---|---|---|---|
单变量模型 | |||
非携带者 | |||
阿司匹林 | 1.0 | - | - |
阿司匹林加氯吡格雷 | 0.98 | 0.56~1.86 | 0.998 |
携带者 | |||
阿司匹林 | 1.0 | - | - |
阿司匹林加氯吡格雷 | 0.72 | 0.67~0.98 | 0.006 |
根据年龄、糖尿病、高血压、吸烟、高脂血症、心肌梗塞史进行调整后 | |||
非携带者 | |||
阿司匹林 | 1.0 | - | - |
阿司匹林加氯吡格雷 | 1.01 | 0.83~2.03 | 0.532 |
携带者 | |||
阿司匹林 | 1.0 | - | - |
阿司匹林加氯吡格雷 | 0.78 | 0.58~0.96 | 0.013 |
表4. 多变量Cox比例风险模型评估与CYP2C19*2基因型和使用阿司匹林或阿司匹林联合氯吡格雷相关的END风险
注:END,早期神经功能恶化;HR,危险比;CI,置信区间。
本研究中,21.2%的急性IS患者发生END,CYP2C19*2功能降低等位基因携带者与血小板活化和END的发生相关,阿司匹林联合氯吡格雷可以降低CYP2C19*2功能降低等位基因携带者END的发生率,但双抗治疗不影响非携带者END发生率。
氯吡格雷是一种无活性前体,需要通过细胞色素P450 (CYP)转化为活性代谢物才能发挥抗血小板作用。CYP2C19*2编码CYP酶,可能影响氯吡格雷转化为其活性代谢物 [
阿司匹林和氯吡格雷有不同的药理机制,可以协同抑制血小板活化 [
本研究局限:1) 样本量偏小、随访时间短、两中心研究,因此,我们的发现有待于将来大样本和多中心研究证实。2) CYP2C19*2 SNPs对血浆氯吡格雷及其活性代谢物水平有影响 [
综上所述,急性动脉粥样硬化型脑梗死END发生率高。CYP2C19*2功能降低等位基因的携带者与END的风险增高有关。阿司匹林联合氯吡格雷能更有效地降低CYP2C19功能降低等位基因携带者的END风险。我们的发现可能有助于指导精确和个性化的抗血小板治疗,降低END的风险。
研究方案由参与医院的伦理委员会根据赫尔辛基宣言规定的原则批准。获得了所有参与者的书面知情同意。
感谢德阳市科学技术研究基金会(批准号2014SZ035)和成都中医药大学科学研究基金会(批准号YYZX1510)对本研究的部分资助。
德阳市2014年度重点科学技术研究项目(2014SZ035);四川省卫生和计划生育委员会科研课题(140025)。
曾 涛,王 淳,易兴阳,王晓明,卿 婷,周 强,林 静. 阿司匹林联合氯吡格雷可降低携带CYP2C19*2功能减退等位基因的缺血性卒中患者早期神经功能恶化的风险Aspirin Plus Clopidogrel May Reduce the Risk of Early Neurologic Deterioration in Ischemic Stroke Patients Carrying CYP2C19*2 Re-duced-Function Alleles[J]. 国际神经精神科学杂志, 2021, 10(02): 65-73. https://doi.org/10.12677/IJPN.2021.102009