上海交通大学学报（医学版）
654 Journal of Shanghai Jiaotong University (Medical Science) Vol. 29 No. 6 Jun. 2009
-----------------------------------------————————————————————————————————————
氯吡格雷联合两种非甾体类解热镇痛药致血小板减少症一例报道 病例报告
孔爱玲，洪 江，张媛媛，戴秋艳，刘少稳
(上海交通大学第一人民医院心内科，上海200080)
中图分类号：R654. 1; R06 文献标志: B 文章编号：02580-5898 (2009) 06-0654-02
在接受冠状动脉支架术治疗的患者中，氯吡格雷和阿司匹林常常联合应用以预防血栓栓塞事件的发生。血小板减少症是与氯吡格雷相关的较少见的并发症，目前国内外偶有相关病例报道。本文报道了1例冠状动脉支架术后在接受氯吡格雷联合两种非甾体类抗炎药治疗后出现血小板减少的患者，进一步探讨其具体机制。
1 临床资料 患者，男，74岁，因反复发作性胸闷2年余，突发胸痛6 h, 于2007年12月18日至上海交通大学附属第一人民医院就诊。心电图显示：II,III, avF 导联ST 段弓背向上抬高0.2 mV, V1 – V3 导联ST 段压低0.3 – 0.5 mV, V7 – V8 导联ST 段抬高0.1 – 0.2 mV。肌钙蛋白I (tropomyosin inhibitory component, Tnl) 2.22 ng/mL, 磷酸肌酸激酶同工酶(creatline kinase – MB, CK – MB) 24. 8 ng/mL, 肌红蛋白(myoglobin, MYO) > 500 ng/mL。诊断为冠心病，急性下壁，后壁心肌梗死。急诊行冠状动脉造影术。术中见左主干(left main coronary artery, LM) 远端管腔40% 下狭窄，左前降支(left anterior descending artery, LAD) 开口处70% 狭窄，右冠状动脉(right coronary artery, RCA) 近端50% 狭窄，后降支(posterior descending coronary atery, PDA) 近端伴血栓形成，管腔完全闭塞。行PDA 球囊扩张，并置入Janus (DES) 3.0 mm x 31 mm 药物支架1枚。患者术前氯吡格雷600 mg, 拜阿司匹林300 mg 顿服，术后氯吡格雷75 mg qd, 拜阿司匹林300 mg qd, 低分子肝素治疗15 d, 因出现一次大便隐血阳性，停用氯吡格雷，拜阿司匹林及低分子肝素。1周后，多次复查粪便隐血阴性，于2008年1月10日再次给予波立维75 mg qd, 拜阿司匹林100 mg qd 口服。1月15日患者出现感冒症状，加服酚氨咖敏片tid，共6 d 后，查血常规显示：血小板34 x 109 / L, 粪隐血阴性，头颅CT 未见出血灶，全身皮肤黏膜未见出血，停用所有抗血小板药物，并输单采血小板1单位。7 d 后复查血常规：血小板259 x 109 / L。考虑患者支架术后，为预防血栓栓塞性事件，于2008年1月29日- 2008年3月3日（共35 d），再次给予氯吡格雷及拜阿司匹林口服，多次复查血常规：血小板(237 – 285) x 109 / L, 白细胞(4.4 – 6.4) x 109 /L, 红细胞(2.34 – 2.79) x 1012 /L, 血红蛋白74 – 91 g/L。病程中凝血全套检测均正常，无出血倾向。无神经系统症状及体征。患者既往无家族史及血液病史。具体数据见表1。
654 Journal of Shanghai Jiaotong University (Medical Science) Vol. 29 No. 6 Jun. 2009
---------------------————————————————————————————————————------------------------------------------
A case of thrombocytopenia
caused by clopidogrel with two non-steroidal antipyretic analgesic drugs
case report
Kong Ai-Ling, Hong Jiang, Zhang Yuan-Yuan, Dai Qiu-Yan and Liu Shao-Wen
(Shanghai Jiaotong University First People’s Hospital Department of Cardiology, Shanghai 200080)
Chinese Library Classification Code: R654.1; R06 Document code: B Article No.: 02580-5898 (2009) 06-0654-02
Clopidogrel is often used with aspirin to prevent thromboembolism with patients who are treated with coronary artery stenting. Thrombocytopenia, a less common complication related to clopidogrel, has been occasionally reported domestically as well as overseas. This article describes a case of thrombocytopenia that has resulted from the use of clopidogrel with two non-steroidal anti-inflammatory drugs after the placement of coronary artery stenting. It also explores the specific mechanism.
1 Clinical information: A 74-year-old male patient sought treatment at First People’s Hospital affiliated to Shanghai Jiaotong University after experiencing a sudden onset of chest pain for 6 hours. Over the past two years he had suffered from recrruent chest distress. An ECG showed II, III, avF lead ST segment arched elevation 0.2 mV, V1-V3 lead ST segment depression 0.3-0.5 mV and V7-V8 lead ST segment arched elevation 0.1-0.2 mV. Troponin I (tropomyosin inhibitory component, TnI) was 2.22 ng/mL, creatine kinase – MB (creatline kinase – MB, CK-MB) 24.8 ng/mL and myoglobin (MYO) > 500 ng/mL. A diagnosis suggested coronary disease and acute inferior and posterior wall myocardial infarction. A coronary artery angiography taken when the patient arrived at the emergency department revealed a left main coronary artery (LM) distal luminal stenosis - 40%, left anterior descending artery (LAD) ostial stenosis - 70%, right coronary artery (RCA) proximal stenosis - 50%, posterior descending coronary artery (PDA) proximal segment with thrombogenesis and complete luminal occlusion. A PDA balloon dilation was performed with the placement of one Janus (DES) 3.0mm x 31mm drug eluting stent. The patient was given preoperatively 600 mg clopidogrel and 300 mg aspirin-ect (aspirin enteric-coated tablet) after meal. Postoperatively he was given 75 mg clopidogrel (qd), 300 mg aspirin-ect (qd) and lower molecular weight heparin for 15 days. Clopidogrel, aspirin-ect and lower molecular weight heparin were stopped with one occurrence of positive stool occult blood. One week later, several more tests showed negative stool occult blood. Subsequently 75 mg Plavix (Clopidogrel) (qd) and 100 mg aspirin-ect (qd) were administered orally on January 10, 2008. On January 15 he complained of symptom of common cold. Thus paracetamol tablets (tid) was added for 6 days. A blood routine indicated platelet - 34 x / L and negative stool occult blood. A cranial CT showed no hemorrhagic foci as well as systemic mucocutaneous hemorrhage. All anti-platelet drugs were stopped, followed by transfusion of one unit of apheresis platelets. Seven days later another blood routine showed platelet - 259 x / L. Between January 29, 2008 and March 3, 2008 (35 days) clopidogrel and aspirin-ect were again administered orally to prevent thromboembolism considering the patient’s stenting placement. More blood routines showed platelet - (237 – 285) x / L, leukocyte - (4.4 – 6.4) x /L, erythrocyte - (2.34 – 2.79) x /L and hemoglobin - 74-91 g/L. The complete cruor measurement was normal. There was no hemorrhage trend. There were no nervous system and physical symptoms. The patient did not have past family and blood disease history. The specific data was shown on Table 1
