De Servi Stefano, Mariani Matteo, Vandoni Pietro, Dellavalle Antonio, Politi Alessandro, Poletti Fabrizio, Bonizzoni Erminio, Leoncinie Mario
Unita' Operativa di Cardiologia, Ospedale Civile di Legnano, Legnano, Italy.
J Cardiovasc Med (Hagerstown). 2006 Mar;7(3):159-65. doi: 10.2459/01.JCM.0000215269.47520.75.
Background In patients with non-ST elevation acute coronary syndrome (NST-ACS) that is treated invasively, glycoprotein (GP) IIb/IIIa inhibitors can be used either as upstream treatment in a coronary care unit or as downstream provisional treatment in selected patients who are undergoing percutaneous coronary intervention (PCI). The relative advantage of either strategy is unknown. The purpose of this study was to assess 30-day outcome of patients enrolled in a prospective NST-ACS registry and treated invasively with either of these two therapeutic strategies. Methods Patients treated invasively (coronary arteriography within 4 days of admission), in the prospective registry ROSAI-2, were divided into two groups according to the upstream use of GPIIb/IIIa inhibitors (n = 241), or not (n = 548). In the latter group, 76 (14%) patients received GPIIb/IIIa in association with a PCI procedure. Clinical and angiographic characteristics as well as in-hospital and 30-day outcome of these two groups of patients were compared. Results The two groups were similar with respect to age, sex, presence of hypertension, diabetes, number of PCI procedures. However, patients treated with upstream GPllb/llla blockers had more frequently ST-segment depression (P = 0.002), a high TIMI risk score (P = 0.01) and were more frequently admitted to centres with Cath Lab facilities (P = 0.001). At 30-day follow-up, the composite of death, acute myocardial infarction and stroke, as well as major bleeding, was not significantly different between the two groups, although it occurred more frequently in patients who received upstream GPIIb/IIIa blockers (9.5% versus 5.7% and 1.7% versus 0.2%, respectively). By multivariate analysis, diabetes [odds ratio (OR) = 2.22, 95% confidence interval (CI) = 1.2-4.09] and a diagnosis on admission of non-Q-wave myocardial infarction (OR = 2.0, 95% Cl = 1.10-3.6) were independently related to outcome. No additional risk or benefit was related to upstream GPIIb/IIIa inhibitor treatment (OR = 1.5, 95% Cl = 0.84-2.68). Conclusions Among invasively-treated patients with NST-ACS, upstream treatment with GPIIb/IIIa inhibitors was used in those with a higher clinical risk profile, whereas downstream treatment was reserved for a limited number of patients undergoing PCI. Thirty-day outcome was similar in the two groups, irrespective of the treatment strategy used.
背景 在接受侵入性治疗的非ST段抬高型急性冠状动脉综合征（NST-ACS）患者中，糖蛋白（GP）IIb/IIIa抑制剂可作为冠心病监护病房的上游治疗用药，也可作为接受经皮冠状动脉介入治疗（PCI）的特定患者的下游临时治疗用药。两种策略的相对优势尚不清楚。本研究的目的是评估纳入前瞻性NST-ACS注册研究并接受这两种治疗策略之一进行侵入性治疗的患者的30天结局。方法 在前瞻性注册研究ROSAI-2中接受侵入性治疗（入院后4天内进行冠状动脉造影）的患者，根据是否上游使用GPIIb/IIIa抑制剂分为两组（n = 241）和未使用组（n = 548）。在后一组中，76例（14%）患者在PCI手术时使用了GPIIb/IIIa。比较了这两组患者的临床和血管造影特征以及住院期间和30天结局。结果 两组在年龄、性别、高血压、糖尿病的存在情况、PCI手术次数方面相似。然而，上游使用GPIIb/IIIa阻滞剂治疗的患者ST段压低更常见（P = 0.002），TIMI风险评分更高（P = 0.01），且更频繁地入住设有心导管室设施的中心（P = 0.001）。在30天随访时，两组之间死亡、急性心肌梗死和中风的复合结局以及大出血情况无显著差异，尽管在接受上游GPIIb/IIIa阻滞剂治疗的患者中更频繁发生（分别为9.5%对5.7%和1.7%对0.2%）。通过多变量分析，糖尿病[比值比（OR）= 2.22，95%置信区间（CI）= 1.2 - 4.09]和入院时诊断为非Q波心肌梗死（OR = 2.0，95%CI = 1.10 - 3.6）与结局独立相关。上游GPIIb/IIIa抑制剂治疗未显示额外的风险或益处（OR = 1.5，95%CI = 0.84 - 2.68）。结论 在接受侵入性治疗的NST-ACS患者中，上游使用GPIIb/IIIa抑制剂治疗的是临床风险较高的患者，而下游治疗则留给有限数量的接受PCI的患者。两组的30天结局相似，无论使用何种治疗策略。
