Heggunje Prabhakara S, Harjai Kishore J, Stone Gregg W, Mehta Rajendra H, Marsalese Dominic L, Boura Judith A, O'Neill William W, Grines Cindy L
William Beaumont Hospital, Royal Oak, Michigan 48073-6769, USA.
J Am Coll Cardiol. 2004 Oct 6;44(7):1400-7. doi: 10.1016/j.jacc.2004.06.065.
We evaluated whether patients' clinical status, angioplasty success, or both, should guide discharge after primary angioplasty (i.e., percutaneous coronary intervention [PCI]) for acute myocardial infarction (AMI).
Current guidelines do not address a discharge strategy for AMI patients undergoing successful PCI.
Patients who underwent PCI in Primary Angioplasty in Myocardial Infarction (PAMI) studies (N = 3,188) were classified as "high clinical risk" if they had either age >70 years, Killip class >1, heart rate >100 beats/min, systolic blood pressure <100 mm Hg, anterior MI, or left bundle branch block, and as "low clinical risk" if none was present. Successful PCI patients were compared with those with unsuccessful PCI in both groups for 30-day major adverse cardiac events (MACE).
Percutaneous coronary intervention was successful in 668 (90%) of 745 low-risk clinical and 2,104 (86%) of 2,443 high-risk clinical patients. Regardless of clinical risk status, patients with successful PCI had lower 30-day MACE than those with unsuccessful PCI (low-risk group: 4.6% vs. 22%, p < 0.0001; high-risk group: 7% vs. 21%; p < 0.0001). Moreover, successful PCI patients with either risk status had few MACE after day 4, whereas unsuccessful PCI patients had more MACE. The success of PCI was the strongest independent predictor of 30-day MACE (odds ratio [OR] 3.7, 95% confidence interval [CI] 2.8 to 5.0). A constellation of three or more high-risk clinical features also predicted higher 30-day MACE (OR 2.25, 95% CI 1.62 to 3.12).
The success of PCI is the prime determinant of clinical outcome after PCI for AMI. The majority of AMI patients with less than three high-risk clinical features who undergo successful PCI may be discharged from the hospital by day 4. In contrast, patients with more than two high-risk clinical features or unsuccessful PCI may need longer observation.
我们评估了在急性心肌梗死（AMI）的直接血管成形术（即经皮冠状动脉介入治疗[PCI]）后，患者的临床状况、血管成形术是否成功或两者是否都应作为出院的指导依据。
当前指南未涉及接受成功PCI的AMI患者的出院策略。
在心肌梗死直接血管成形术（PAMI）研究中接受PCI的患者（N = 3188），若年龄>70岁、Killip分级>1、心率>100次/分钟、收缩压<100 mmHg、前壁心肌梗死或左束支传导阻滞，则被分类为“高临床风险”，若不存在上述任何一项，则被分类为“低临床风险”。在两组中，将成功进行PCI的患者与未成功进行PCI的患者进行30天主要不良心脏事件（MACE）的比较。
745例低风险临床患者中有668例（90%）、2443例高风险临床患者中有2104例（86%）的经皮冠状动脉介入治疗成功。无论临床风险状况如何，成功进行PCI的患者30天MACE发生率均低于未成功进行PCI的患者（低风险组：4.6%对22%，p<0.0001；高风险组：7%对21%；p<0.0001）。此外，无论风险状况如何，成功进行PCI的患者在第4天后发生的MACE较少，而未成功进行PCI的患者发生的MACE较多。PCI的成功是30天MACE最强的独立预测因素（优势比[OR] 3.7，95%置信区间[CI] 2.8至5.0）。三种或更多高风险临床特征的组合也预示着30天MACE发生率更高（OR 2.25，95% CI 1.62至3.12）。
PCI的成功是AMI患者PCI后临床结局的主要决定因素。大多数接受成功PCI且具有少于三种高风险临床特征的AMI患者可能在第4天出院。相比之下，具有两种以上高风险临床特征或PCI未成功的患者可能需要更长时间的观察。
