Schömig A, Kastrati A, Dirschinger J, Mehilli J, Schricke U, Pache J, Martinoff S, Neumann F J, Schwaiger M
Deutsches Herzzentrum, 1. Medizinische Klinik rechts der Isar, Munich, Germany.
N Engl J Med. 2000 Aug 10;343(6):385-91. doi: 10.1056/NEJM200008103430602.
Prevention of myocardial damage is the main goal of all reperfusion therapies in patients with acute myocardial infarction. The relative efficacy of various reperfusion strategies is under intensive investigation. We assessed whether coronary stenting combined with the blockade of platelet glycoprotein IIb/IIIa receptors produces a greater degree of myocardial salvage than fibrinolysis with an accelerated infusion of alteplase, a tissue plasminogen activator, in patients with acute myocardial infarction.
A total of 140 patients were enrolled in the randomized trial; 71 were assigned to receive a stent plus abciximab, and 69 to receive intravenous alteplase. The primary end point was the degree of myocardial salvage, determined by means of serial scintigraphic studies with technetium Tc 99m sestamibi. The secondary end point was a composite of death, reinfarction, and stroke within six months after randomization.
In the group that received a stent plus abciximab, the median size of the final infarct was 14.3 percent of the left ventricle (25th and 75th percentiles, 6.8 and 24.5 percent), as compared with a median of 19.4 percent (25th and 75th percentiles, 7.9 and 34.2 percent) in the alteplase group (P=0.02). This difference was due to the larger salvage index (the percentage of the left ventricle that was salvaged, divided by the percentage that was compromised by the initial perfusion defect) in the stent group: 0.57 (25th and 75th percentiles, 0.35 and 0.69), as compared with 0.26 (25th and 75th percentiles, 0.09 and 0.61; P<0.001). The cumulative incidence of death, reinfarction, or stroke at six months was lower in the stent group than in the alteplase group (8.5 vs. 23.2 percent. P=0.02; relative risk, 0.34; 95 percent confidence interval, 0.13 to 0.88).
In patients with acute myocardial infarction, coronary stenting plus abciximab leads to a greater degree of myocardial salvage and a better clinical outcome than does fibrinolysis with a tissue plasminogen activator.
预防心肌损伤是急性心肌梗死患者所有再灌注治疗的主要目标。各种再灌注策略的相对疗效正在深入研究中。我们评估了在急性心肌梗死患者中，冠状动脉支架置入术联合血小板糖蛋白IIb/IIIa受体阻滞剂是否比加速输注组织纤溶酶原激活剂阿替普酶进行溶栓能产生更大程度的心肌挽救。
共有140例患者纳入随机试验；71例被分配接受支架加阿昔单抗治疗，69例接受静脉注射阿替普酶治疗。主要终点是心肌挽救程度，通过用锝Tc 99m司他米比进行系列闪烁扫描研究来确定。次要终点是随机分组后6个月内死亡、再梗死和中风的复合终点。
在接受支架加阿昔单抗治疗的组中，最终梗死灶的中位数大小为左心室的14.3%（第25和第75百分位数分别为6.8%和24.5%），而阿替普酶组的中位数为19.4%（第25和第75百分位数分别为7.9%和34.2%）（P=0.02）。这种差异是由于支架组的挽救指数（左心室被挽救的百分比除以因初始灌注缺损而受损的百分比）更大：0.57（第25和第75百分位数分别为0.35和0.69），而阿替普酶组为0.26（第25和第75百分位数分别为0.09和0.61；P<0.001）。支架组6个月时死亡、再梗死或中风的累积发生率低于阿替普酶组（8.5%对23.2%，P=0.02；相对风险，0.34；95%置信区间，0.13至0.88）。
在急性心肌梗死患者中，冠状动脉支架置入术加阿昔单抗比用组织纤溶酶原激活剂进行溶栓能产生更大程度的心肌挽救和更好的临床结局。
