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纤溶和急诊PCI治疗ST段抬高型心肌梗死的比较
Fibrinolysis or Primary PCI in ST-Segment Elevation Myocardial Infarction


Paul W. Armstrong ... 心脑血管疾病 • 2013.04.11
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• 急性心肌梗死

摘要


背景

在急性ST段抬高型心肌梗死(STEMI)发生后,院前纤溶加及时冠状动脉血管造影与早期急诊经皮冠状动脉介入治疗(PCI)的临床效果是否相似,目前对此尚不了解。

 

方法

将1,892例在症状出现后3小时内入院、且不能在1小时内进行急诊PCI的 STEMI患者,随机分组,或接受急诊PCI治疗,或在转至可施行PCI的医院前应用替奈普酶(对年龄≥75岁的患者剂量减半)、氯吡格雷以及依诺肝素纤溶治疗。若纤溶失败,则进行急诊冠状动脉血管造影;否则,随机分组后6~24小时进行血管造影。主要终点是由30天内死亡、休克、充血性心力衰竭或再梗死组成的复合终点。

 

结果

纤溶组的939例患者中116例(12.4%)、急诊PCI组的943例患者中135例(14.3%)发生了主要终点(纤溶组相对危险,0.86;95%可信区间,0.68~1.09;P=0.21)。纤溶组患者中36.3%需要急诊血管造影,而其余患者在随机化后中位时间17小时进行了血管造影。纤溶组颅内出血发生率高于急诊PCI组(1.0%对0.2%,P=0.04;方案修订后,0.5%对0.3%,P=0.45)。两组非颅内出血发生率相似。

 

结论

院前纤溶加及时冠状动脉造影能为那些在初次医疗接触1小时内不能进行急诊PCI的STEMI早期患者提供有效再灌注。但是,纤溶和颅内出血的风险轻微增加相关(由勃林格殷格翰公司[Boehringer Ingelheim]资助,ClinicalTrials.gov注册号为NCT0062362)。





作者信息

Paul W. Armstrong, M.D., Anthony H. Gershlick, M.D., Patrick Goldstein, M.D., Robert Wilcox, M.D., Thierry Danays, M.D., Yves Lambert, M.D., Vitaly Sulimov, M.D., Ph.D., Fernando Rosell Ortiz, M.D., Ph.D., Miodrag Ostojic, M.D., Ph.D., Robert C. Welsh, M.D., Antonio C. Carvalho, M.D., Ph.D., John Nanas, M.D., Ph.D., Hans-Richard Arntz, M.D., Ph.D., Sigrun Halvorsen, M.D., Ph.D., Kurt Huber, M.D., Stefan Grajek, M.D., Ph.D., Claudio Fresco, M.D., Erich Bluhmki, M.D., Ph.D., Anne Regelin, Ph.D., Katleen Vandenberghe, Ph.D., Kris Bogaerts, Ph.D., and Frans Van de Werf, M.D., Ph.D., for the STREAM Investigative Team*
The authors' affiliations are listed in the Appendix. Address reprint requests to Dr. Van de Werf at the Department of Cardiovascular Sciences, University Hospitals Leuven, KU Leuven, Herestraat 49, B-3000 Leuven, Belgium, or at frans.vandewerf@med.kuleuven.be. *Committees and investigators for the Strategic Reperfusion Early after Myocardial Infarction (STREAM) study are listed in the Supplementary Appendix, available at NEJM.org.

 

参考文献

1. Steg PG, James SK, Atar D, et al. ESC guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation. Eur Heart J 2012;33:2569-2619

2. O'Gara PT, Kushner FG, Ascheim DD, et al. 2013 ACCF/AHA Guideline for the Management of ST-Elevation Myocardial Infarction: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol 2013;61:e78-e140

3. Armstrong PW, Boden WE. Reperfusion paradox in ST-segment elevation myocardial infarction. Ann Intern Med 2011;155:389-391

4. Roe MT, Messenger JC, Weintraub WS, et al. Treatments, trends, and outcomes of acute myocardial infarction and percutaneous coronary intervention. J Am Coll Cardiol 2010;56:254-263

5. Terkelsen CJ, Sorensen JT, Maeng M, et al. System delay and mortality among patients with STEMI treated with primary percutaneous coronary intervention. JAMA 2010;304:763-771

6. Pinto DS, Frederick PD, Chakrabarti AK, et al. Benefit of transferring ST-segment-elevation myocardial infarction patients for percutaneous coronary intervention compared with administration of onsite fibrinolytic declines as delays increase. Circulation 2011;124:2512-2521

7. Armstrong PW, Westerhout CM, Welsh RC. Duration of symptoms is the key modulator of the choice of reperfusion for ST-elevation myocardial infarction. Circulation 2009;119:1293-1303

8. Armstrong PW, Gershlick A, Goldstein P, et al. The Strategic Reperfusion Early After Myocardial Infarction (STREAM) study. Am Heart J 2010;160(1):30.e1-35.e1.

9. Larson DM, Duval S, Sharkey SW, et al. Safety and efficacy of a pharmaco-invasive reperfusion strategy in rural ST-elevation myocardial infarction patients with expected delays due to long-distance transfers. Eur Heart J 2012;33:1232-1240

10. Harrell FE Jr. Hmisc: Harrell Miscellaneous — R package, version 3.8-3. 2010 (http://cran.r-project.org/package=Hmisc).

11. Andersen HR, Nielsen TT, Rasmussen K, et al. A comparison of coronary angioplasty with fibrinolytic therapy in acute myocardial infarction. N Engl J Med 2003;349:733-742

12. Primary versus tenecteplase-facilitated percutaneous coronary intervention in patients with ST-segment elevation acute myocardial infarction (ASSENT-4 PCI): randomised trial. Lancet 2006;367:569-578

13. Brouwer MA, Martin JS, Maynard C, et al. Influence of early prehospital thrombolysis on mortality and event-free survival (the Myocardial Infarction Triage and Intervention [MITI] Randomized Trial). Am J Cardiol 1996;78:497-502

14. Westerhout CM, Bonnefoy E, Welsh RC, Steg PG, Boutitie F, Armstrong PW. The influence of time from symptom onset and reperfusion strategy on 1-year survival in ST-elevation myocardial infarction: a pooled analysis of an early fibrinolytic strategy versus primary percutaneous coronary intervention from CAPTIM and WEST. Am Heart J 2011;161:283-290

15. Kaul S, Diamond GA, Weintraub WS. Trials and tribulations of non-inferiority: the ximelagatran experience. J Am Coll Cardiol 2005;46:1986-1995

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