急性心肌梗死溶栓治疗失败后的挽救性血管成形术。

Rescue angioplasty after failed thrombolytic therapy for acute myocardial infarction.

作者信息

Gershlick Anthony H, Stephens-Lloyd Amanda, Hughes Sarah, Abrams Keith R, Stevens Suzanne E, Uren Neal G, de Belder Adam, Davis John, Pitt Michael, Banning Adrian, Baumbach Andreas, Shiu Man Fai, Schofield Peter, Dawkins Keith D, Henderson Robert A, Oldroyd Keith G, Wilcox Robert

机构信息

Department of Cardiology, University Hospitals of Leicester, Leicester, United Kingdom.

出版信息

N Engl J Med. 2005 Dec 29;353(26):2758-68. doi: 10.1056/NEJMoa050849.

DOI:10.1056/NEJMoa050849

PMID:16382062

Abstract

BACKGROUND

The appropriate treatment for patients in whom reperfusion fails to occur after thrombolytic therapy for acute myocardial infarction remains unclear. There are few data comparing emergency percutaneous coronary intervention (rescue PCI) with conservative care in such patients, and none comparing rescue PCI with repeated thrombolysis.

METHODS

We conducted a multicenter trial in the United Kingdom involving 427 patients with ST-segment elevation myocardial infarction in whom reperfusion failed to occur (less than 50 percent ST-segment resolution) within 90 minutes after thrombolytic treatment. The patients were randomly assigned to repeated thrombolysis (142 patients), conservative treatment (141 patients), or rescue PCI (144 patients). The primary end point was a composite of death, reinfarction, stroke, or severe heart failure within six months.

RESULTS

The rate of event-free survival among patients treated with rescue PCI was 84.6 percent, as compared with 70.1 percent among those receiving conservative therapy and 68.7 percent among those undergoing repeated thrombolysis (overall P=0.004). The adjusted hazard ratio for the occurrence of the primary end point for repeated thrombolysis versus conservative therapy was 1.09 (95 percent confidence interval, 0.71 to 1.67; P=0.69), as compared with adjusted hazard ratios of 0.43 (95 percent confidence interval, 0.26 to 0.72; P=0.001) for rescue PCI versus repeated thrombolysis and 0.47 (95 percent confidence interval, 0.28 to 0.79; P=0.004) for rescue PCI versus conservative therapy. There were no significant differences in mortality from all causes. Nonfatal bleeding, mostly at the sheath-insertion site, was more common with rescue PCI. At six months, 86.2 percent of the rescue-PCI group were free from revascularization, as compared with 77.6 percent of the conservative-therapy group and 74.4 percent of the repeated-thrombolysis group (overall P=0.05).

CONCLUSIONS

Event-free survival after failed thrombolytic therapy was significantly higher with rescue PCI than with repeated thrombolysis or conservative treatment. Rescue PCI should be considered for patients in whom reperfusion fails to occur after thrombolytic therapy.

摘要

背景

急性心肌梗死溶栓治疗后再灌注未成功的患者的恰当治疗方法仍不明确。比较此类患者急诊经皮冠状动脉介入治疗（补救性经皮冠状动脉介入治疗）与保守治疗的数据很少，且尚无比较补救性经皮冠状动脉介入治疗与重复溶栓治疗的数据。

方法

我们在英国开展了一项多中心试验，纳入427例ST段抬高型心肌梗死患者，这些患者在溶栓治疗后90分钟内再灌注未成功（ST段回落小于50%）。患者被随机分配至重复溶栓治疗组（142例患者）、保守治疗组（141例患者）或补救性经皮冠状动脉介入治疗组（144例患者）。主要终点为6个月内死亡、再梗死、卒中或严重心力衰竭的复合终点。

结果

接受补救性经皮冠状动脉介入治疗的患者无事件生存率为84.6%，接受保守治疗的患者为70.1%，接受重复溶栓治疗的患者为68.7%（总体P=0.004）。重复溶栓治疗与保守治疗相比，主要终点发生的校正风险比为1.09（95%置信区间为0.71至1.67；P=0.69），而补救性经皮冠状动脉介入治疗与重复溶栓治疗相比的校正风险比为0.43（95%置信区间为0.26至0.72；P=0.001），补救性经皮冠状动脉介入治疗与保守治疗相比的校正风险比为0.47（95%置信区间为0.28至0.79；P=0.004）。全因死亡率无显著差异。非致命性出血大多发生在鞘管插入部位，在补救性经皮冠状动脉介入治疗中更常见。6个月时，补救性经皮冠状动脉介入治疗组86.2%的患者无需进行血管重建，保守治疗组为77.6%，重复溶栓治疗组为74.4%（总体P=0.05）。