Racine Eric
Intern Med/CNS Business Unit, Sanofi-Synthelabo US, 90 Park Avenue, New York, NY 10016, USA.
Am J Health Syst Pharm. 2002 Nov 1;59(21 Suppl 7):S27-36. doi: 10.1093/ajhp/59.suppl_7.S27.
The role of glycoprotein (GP) IIb/IIIa-receptor inhibitors in managing ST-segment-elevation (STE) myocardial infarction (MI) is discussed. Strategies to improve outcomes in patients with STE MI have been directed toward rapidly establishing early reperfusion of the infarct-related artery and the downstream myocardial microvasculature and preventing reocclusion. Because of its superiority to fibrinolytic reperfusion, percutaneous coronary intervention (PCI) has emerged as the treatment of choice in patients with STE MI, including patients who are initially admitted to facilities not equipped to perform PCI. The combination of reduced doses of fibrinolytic agents with the GP IIb/IIIa-receptor inhibitors abciximab and eptifibatide has been explored as a means of improving reperfusion, both without PCI and as a means of facilitating PCI. Two large studies of the combination of abciximab and a reduced dose of a fibrinolytic agent in patients not undergoing PCI found a significant reduction in reinfarction, but mortality rates were unaffected and the risk of bleeding complications and thrombocytopenia was increased compared with the full dose of fibrinolytic agents alone. More encouraging results were seen with abciximab (with and without fibrinolytic therapy) in patients undergoing PCI. Pretreatment with eptifibatide (with and without concomitant fibrinolytic therapy) increased reperfusion prior to PCI, setting the stage for a large ongoing trial of eptifibatide in patients with STE MI undergoing PCI. This trial may help define the new standard of care for patients with STE MI, including the optimal use of GP IIb/IIIa-receptor inhibitors. Recent clinical trials in patients with STE MI show that the use of a GP IIb/IIIa-receptor inhibitor (with or without concomitant therapy with a reduced dose of a fibrinolytic agent) in conjunction with early PCI holds promise for achieving higher reperfusion rates and reducing the frequency of ischemic events.
本文讨论了糖蛋白（GP）IIb/IIIa受体抑制剂在ST段抬高型（STE）心肌梗死（MI）治疗中的作用。改善STE心肌梗死患者预后的策略一直致力于迅速实现梗死相关动脉及其下游心肌微血管的早期再灌注，并预防再闭塞。由于经皮冠状动脉介入治疗（PCI）优于纤维蛋白溶解再灌注治疗，它已成为STE心肌梗死患者的首选治疗方法，包括最初被收治到不具备PCI条件的医疗机构的患者。已探索将低剂量纤维蛋白溶解剂与GP IIb/IIIa受体抑制剂阿昔单抗和依替巴肽联合使用，作为在不进行PCI的情况下改善再灌注的一种方法，以及作为促进PCI的一种手段。两项关于在未接受PCI的患者中联合使用阿昔单抗和低剂量纤维蛋白溶解剂的大型研究发现，再梗死率显著降低，但死亡率未受影响，与单独使用全剂量纤维蛋白溶解剂相比，出血并发症和血小板减少的风险增加。在接受PCI的患者中，阿昔单抗（无论是否进行纤维蛋白溶解治疗）取得了更令人鼓舞的结果。依替巴肽预处理（无论是否同时进行纤维蛋白溶解治疗）可增加PCI前的再灌注，为正在进行的一项针对接受PCI的STE心肌梗死患者使用依替巴肽的大型试验奠定了基础。该试验可能有助于确定STE心肌梗死患者的新治疗标准，包括GP IIb/IIIa受体抑制剂的最佳使用方法。最近针对STE心肌梗死患者的临床试验表明，将GP IIb/IIIa受体抑制剂（无论是否同时使用低剂量纤维蛋白溶解剂）与早期PCI联合使用，有望实现更高的再灌注率并减少缺血事件的发生频率。
