Maggioni A P, Franzosi M G, Santoro E, White H, Van de Werf F, Tognoni G
GISSI-2 Coordinating Center, Milan, Italy.
N Engl J Med. 1992 Jul 2;327(1):1-6. doi: 10.1056/NEJM199207023270101.
Many trials in patients with acute myocardial infarction have demonstrated that thrombolytic therapy is not associated with an excessive risk of stroke, as compared with conventional treatment. However, the incidence of various forms of stroke in patients treated with different thrombolytic and antithrombotic regimens and the associated effect of risk factors for stroke are largely unknown.
Strokes occurring in patients hospitalized with acute myocardial infarction who were enrolled in either of two large trials were analyzed. The patients were randomly assigned to receive streptokinase (1.5 million units) or recombinant tissue plasminogen activator (t-PA) (100 mg) and also randomly assigned to receive subcutaneous heparin or no heparin. Ninety-one percent of the patients also received aspirin.
Complete data were available on 20,768 patients. A total of 236 (1.14 percent) had strokes in the hospital; 0.36 percent had hemorrhagic strokes, 0.48 percent ischemic strokes, and 0.30 percent strokes of undefined cause. Patients treated with t-PA had a small but significant excess of stroke as compared with those who received streptokinase (1.33 vs. 0.94 percent; adjusted odds ratio, 1.42; 95 percent confidence interval, 1.09 to 1.84). The administration of subcutaneous heparin in addition to a thrombolytic agent did not increase the risk of stroke (risk with heparin, 1.13 percent; without heparin, 1.14 percent). Older age, a higher Killip class, and the occurrence of anterior infarction significantly increased the risk of stroke, whereas a higher body-mass index or a history of hypertension, diabetes, or smoking did not.
Patients with acute myocardial infarction who receive thrombolytic therapy have a small risk of stroke. Treatment with t-PA as compared with streptokinase resulted in a small but significant excess of stroke. Subcutaneous heparin, given together with t-PA or streptokinase and aspirin, did not result in an increased risk of stroke.
许多针对急性心肌梗死患者的试验表明，与传统治疗相比，溶栓治疗不会增加过多的中风风险。然而，接受不同溶栓和抗血栓治疗方案的患者中各种类型中风的发生率以及中风危险因素的相关影响在很大程度上尚不清楚。
对参加两项大型试验之一的急性心肌梗死住院患者发生的中风进行分析。患者被随机分配接受链激酶（150万单位）或重组组织型纤溶酶原激活剂（t-PA）（100毫克），并且还被随机分配接受皮下肝素或不接受肝素。91%的患者还接受了阿司匹林治疗。
共有20768例患者获得完整数据。总共有236例（1.14%）患者在住院期间发生中风；0.36%为出血性中风，0.48%为缺血性中风，0.30%为病因不明的中风。与接受链激酶治疗的患者相比，接受t-PA治疗的患者中风发生率虽小但有显著增加（分别为1.33%和0.94%；校正比值比为1.42；95%置信区间为1.09至1.84）。除溶栓剂外给予皮下肝素并未增加中风风险（使用肝素时的风险为1.13%；不使用肝素时为1.14%）。年龄较大、Killip分级较高以及发生前壁梗死显著增加中风风险，而较高的体重指数或高血压、糖尿病或吸烟史则未增加中风风险。
接受溶栓治疗的急性心肌梗死患者有较小的中风风险。与链激酶相比，t-PA治疗导致中风发生率虽小但有显著增加。与t-PA或链激酶及阿司匹林联合使用时，皮下肝素不会增加中风风险。
