Ruocco N A, Bergelson B A, Jacobs A K, Frederick M M, Faxon D P, Ryan T J
Evans Memorial Department of Clinical Research, Boston University Medical Center, Massachusetts.
J Am Coll Cardiol. 1992 Dec;20(7):1445-51. doi: 10.1016/0735-1097(92)90435-p.
This study was designed to assess the possibility that a subgroup of patients at high risk for recurrent ischemia and reinfarction after thrombolytic therapy might benefit from early intervention.
The Thrombolysis in Myocardial Infarction Phase II (TIMI II) study recently concluded that an obligatory invasive strategy after thrombolytic therapy offered no advantage over a more conservative strategy.
Data from the 3,534 patients enrolled in the TIMI II trial were analyzed to determine whether a history of antecedent angina before myocardial infarction identifies patients at high risk for subsequent ischemia and whether these patients might benefit from an invasive strategy.
Within the TIMI II population, antecedent angina identified patients at increased risk for recurrent chest pain in the hospital (32.3% vs. 22.1%, p < 0.001) and recurrent infarction during the 1st year of follow-up (11.2% vs. 7.9%, p = 0.001) compared with that of patients without antecedent angina. Among patients assigned to the invasive strategy, coronary arteriography revealed that those with antecedent angina had a more severe residual stenosis of the infarct-related artery after thrombolytic therapy (77.1 +/- 0.7% vs. 73.0 +/- 0.9%, p < 0.001) and more multivessel disease (37.9% vs. 26.4%, p < 0.001). The clinical outcome of the patients with antecedent angina assigned randomly to either the invasive or the conservative strategy were compared. The invasive strategy patients had a slightly lesser incidence of recurrent chest pain in the hospital (29.9% vs. 34.8%, p = 0.13) and more negative (normal) findings on exercise tolerance tests (24.7 vs. 18.9%, p = 0.003), but there was no difference between the treatment strategies in the end point variable of recurrent myocardial infarction or death.
These data demonstrate that antecedent angina identifies patients at increased risk for recurrent ischemic events after thrombolytic therapy. However, similar to the results for the overall population, the invasive strategy does not alter the risk of reinfarction or death compared with the conservative approach.
本研究旨在评估溶栓治疗后复发缺血和再梗死高危患者亚组可能从早期干预中获益的可能性。
心肌梗死溶栓治疗II期（TIMI II）研究最近得出结论，溶栓治疗后强制性侵入性策略并不比更保守的策略更具优势。
分析了TIMI II试验中3534例患者的数据，以确定心肌梗死前有前驱性心绞痛病史的患者是否为后续缺血的高危患者，以及这些患者是否可能从侵入性策略中获益。
在TIMI II人群中，与无前驱性心绞痛的患者相比，前驱性心绞痛患者在住院期间复发性胸痛的风险增加（32.3%对22.1%，p<0.001），在随访第1年复发性梗死的风险增加（11.2%对7.9%，p = 0.001）。在接受侵入性策略的患者中，冠状动脉造影显示，有前驱性心绞痛的患者在溶栓治疗后梗死相关动脉的残余狭窄更严重（77.1±0.7%对73.0±0.9%，p<0.001），多支血管病变更多（37.9%对26.4%，p<0.001）。比较了随机分配到侵入性或保守性策略的有前驱性心绞痛患者的临床结局。侵入性策略组患者在住院期间复发性胸痛的发生率略低（29.9%对34.8%，p = 0.13），运动耐量试验的阴性（正常）结果更多（24.7对18.9%，p = 0.003），但在复发性心肌梗死或死亡的终点变量方面，治疗策略之间没有差异。
这些数据表明，前驱性心绞痛可识别溶栓治疗后复发性缺血事件风险增加的患者。然而，与总体人群的结果相似，与保守方法相比，侵入性策略并未改变再梗死或死亡的风险。
