Popma J J, Califf R M, Ellis S G, George B S, Kereiakes D J, Samaha J K, Worley S J, Anderson J L, Stump D, Woodlief L
Department of Internal Medicine (Cardiology Division), University of Michigan Medical Center, Ann Arbor.
J Am Coll Cardiol. 1992 Nov 15;20(6):1305-12. doi: 10.1016/0735-1097(92)90241-e.
The goal of this study was to lend insight into the mechanisms responsible for the beneficial effects of combination thrombolytic therapy.
Combination thrombolytic therapy for acute myocardial infarction has been associated with less reocclusion and fewer in-hospital clinical events than has monotherapy.
Infarct-related quantitative coronary dimensions and hemostatic protein levels were evaluated in 287 patients with acute myocardial infarction during the early (90-min) and convalescent (7-day) phases after administration of recombinant tissue-type plasminogen activator (rt-PA), urokinase or combination rt-PA and urokinase.
Minimal lumen diameter was similar in the 90-min and 7-day phases after treatment with rt-PA, urokinase and combination rt-PA and urokinase (0.72 +/- 0.45 mm, 0.62 +/- 0.53 mm and 0.75 +/- 0.58 mm, respectively, at 90 min, p = 0.16; and 1.05 +/- 0.56 mm, 1.12 +/- 0.72 mm and 0.94 +/- 0.54 mm, respectively, at 7 days, p = 0.22). In-hospital clinical event and reocclusion rates were less frequent in patients receiving combination therapy than in those receiving monotherapy (25% vs. 38% and 32% for rt-PA and urokinase, respectively, p = 0.084; and 3% vs. 13% and 9% for rt-PA and urokinase, respectively, p = 0.03), but these events were unrelated to early or late coronary dimensions. Patients receiving combination therapy or urokinase monotherapy had significantly higher peak fibrin degradation products (1,307 +/- 860 and 1,285 +/- 898 micrograms/ml vs. 435 +/- 717 micrograms/ml, respectively, p < 0.0001) and lower nadir fibrinogen levels (0.85 +/- 1.00 and 0.75 +/- 0.53 g/liter vs. 1.90 +/- 0.86 g/liter, respectively, p < 0.0001) than did those receiving rt-PA monotherapy. Peak fibrinogen degradation products indirectly correlated (p = 0.004) and baseline (p = 0.026) and nadir (p = 0.089) fibrinogen levels directly correlated with reocclusion.
Lower in-hospital clinical event and reocclusion rates observed with combination thrombolytic therapy may relate to systemic hematologic factors rather than to the residual lumen obstruction after thrombolysis.
本研究的目的是深入了解联合溶栓治疗产生有益效果的机制。
与单一疗法相比，急性心肌梗死的联合溶栓治疗与再闭塞减少和院内临床事件减少相关。
在287例急性心肌梗死患者中，于给予重组组织型纤溶酶原激活剂（rt-PA）、尿激酶或rt-PA与尿激酶联合治疗后的早期（90分钟）和恢复期（7天）评估梗死相关冠状动脉定量尺寸和止血蛋白水平。
rt-PA、尿激酶以及rt-PA与尿激酶联合治疗后90分钟和7天时的最小管腔直径相似（90分钟时分别为0.72±0.45mm、0.62±0.53mm和0.75±0.58mm，p = 0.16；7天时分别为1.05±0.56mm、1.12±0.72mm和0.94±0.54mm，p = 0.22）。联合治疗组患者的院内临床事件和再闭塞率低于单一治疗组（rt-PA组和尿激酶组分别为25% vs. 38%和32%，p = 0.084；rt-PA组和尿激酶组分别为3% vs. 13%和9%，p = 0.03），但这些事件与早期或晚期冠状动脉尺寸无关。接受联合治疗或尿激酶单一治疗的患者的纤维蛋白降解产物峰值显著更高（分别为1,307±860和1,285±898μg/ml，而rt-PA单一治疗组为435±717μg/ml，p < 0.0001），最低点纤维蛋白原水平更低（分别为0.85±1.00和0.75±0.53g/L，而rt-PA单一治疗组为1.90±0.86g/L，p < 0.0001）。纤维蛋白原降解产物峰值间接相关（p = 0.004），基线（p = 0.026）和最低点（p = 0.089）纤维蛋白原水平与再闭塞直接相关。
联合溶栓治疗观察到的较低院内临床事件和再闭塞率可能与全身血液学因素有关，而非与溶栓后的残余管腔阻塞有关。
