Armstrong Paul W, Chang Wei-Ching, Wallentin Lars, Goldstein Patrick, Granger Christopher B, Bogaerts Kris, Danays Thierry, Van de Werf Frans
University of Alberta, Edmonton, Alta.
CMAJ. 2006 May 9;174(10):1421-6. doi: 10.1503/cmaj.051410.
The optimal antithrombotic therapy to accompany tenecteplase in cases of acute ST-segment elevation myocardial infarction (STEMI) remains unclear. We undertook a prespecified pooled analysis of data from the ASSENT-3 and ASSENT-3 PLUS trials.
We created a combined database of the 2040 and 818 patients who received enoxaparin in ASSENT-3 and ASSENT-3 PLUS, respectively, and compared them with the 2038 and 821 patients who received unfractionated heparin.
The efficacy end point (a composite of 30-day mortality, reinfarction or refractory ischemia) was 12.2% with enoxaparin versus 16.0% with unfractionated heparin (p < 0.001); the combined end point of efficacy plus safety (a composite of 30-day mortality, reinfarction, refractory ischemia, intracranial hemorrhage [ICH] or major systemic bleeding) was 15.0% versus 18.0%, respectively (p = 0.003) [corrected] The 1049 patients urgently revascularized had greater benefit from enoxaparin (15.4% v. 10.1%, p = 0.013), yet the excess in major systemic bleeding evident with enoxaparin (3.3% v. 2.4%, p = 0.01) was largely confined to the 3492 patients without or before revascularization. Although ICH rates in the groups were similar (1.3% v. 0.9%, p = 0.26), an excess of ICH occurred among those administered enoxaparin during the ASSENT-3 PLUS trial (6.7% v. 0.8%, p = 0.013), especially among women over 75 years of age.
These data demonstrated the benefit of enoxaparin used in conjunction with tenecteplase, but raised caution about its prehospital use to treat STEMI in elderly women.
在急性ST段抬高型心肌梗死（STEMI）病例中，与替奈普酶联合使用的最佳抗栓治疗方案仍不明确。我们对ASSENT - 3和ASSENT - 3 PLUS试验的数据进行了预先设定的汇总分析。
我们分别创建了ASSENT - 3和ASSENT - 3 PLUS试验中接受依诺肝素治疗的2040例和818例患者的合并数据库，并将他们与接受普通肝素治疗的2038例和821例患者进行比较。
依诺肝素组的疗效终点（30天死亡率、再梗死或难治性缺血的复合终点）为12.2%，而普通肝素组为16.0%（p < 0.001）；疗效加安全性的联合终点（30天死亡率、再梗死、难治性缺血、颅内出血[ICH]或严重全身性出血的复合终点）分别为15.0%和18.0%（p = 0.003）[校正后]。1049例紧急进行血管重建的患者从依诺肝素中获益更大（15.4%对10.1%，p = 0.013），然而依诺肝素明显的严重全身性出血过量（3.3%对2.4%，p = 0.01）主要局限于3492例未进行血管重建或在血管重建之前的患者。尽管两组的ICH发生率相似（1.3%对0.9%，p = 0.26），但在ASSENT - 3 PLUS试验期间，接受依诺肝素治疗的患者中ICH过量发生（6.7%对0.8%，p = 0.013），尤其是75岁以上的女性。
这些数据证明了依诺肝素与替奈普酶联合使用的益处，但对于在老年女性中院前使用依诺肝素治疗STEMI提出了警示。
