Sejersten M, Birnbaum Y, Ripa R S, Maynard C, Wagner G S, Clemmensen P
Department of Cardiology B, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark.
Heart. 2006 Nov;92(11):1577-82. doi: 10.1136/hrt.2005.085639. Epub 2006 Jun 1.
To determine whether ischaemia grade (GI) on the presenting ECG and duration of symptoms can identify subgroups of patients who would derive more benefit than the general population of patients with ST segment elevation acute myocardium infarction (STEMI) from primary percutaneous coronary intervention (pPCI) over thrombolytic treatment (TT) in reducing mortality or reinfarction.
1319 DANAMI-2 (Danish trial in Acute Myocardial Infarction-2) patients were classified as having grade 2 ischaemia (GI2; ST segment elevation without terminal QRS distortion) or grade 3 ischaemia (GI3; ST segment elevation with terminal QRS distortion in > or = 2 adjacent leads), and were divided into early and late groups split by the median time (3 h) from symptom onset to treatment. Outcomes were 30-day mortality and reinfarction.
Mortality was significantly higher for GI3 than for GI2 (9.7% v 4.8%, p < 0.001) and doubled for patients presenting late (GI2: 6.0% v 3.3%, p = 0.01; GI3: 12.5% v 4.7%, p = 0.05). Overall mortality did not differ significantly between pPCI and TT; however, a 5.5% absolute mortality reduction was seen in GI3 treated early with pPCI (1.4% v 6.9%, p = 0.10). Reinfarction rate was particularly high among GI3 patients presenting late and treated with TT (12.2%). pPCI in such patients significantly reduced the rate of reinfarction (0%, p < 0.001). Logistic regression analysis showed that age (odds ratio (OR) 1.09, 95% confidence interval (CI) 1.06 to 1.12, p < 0.001), prior angina (OR 2.56, 95% CI 1.44 to 4.54, p = 0.001), heart rate (OR 1.03, 95% CI 1.01 to 1.04, p = 0.001) and GI3 (OR 1.91, 95% CI 1.06 to 3.44, p = 0.031) were independently associated with mortality, whereas the sum of ST segment elevation was not.
GI3 is an independent predictor of mortality among patients with STEMI. Mortality increased significantly with symptom duration in both GI2 and GI3. pPCI may be especially beneficial for patients with GI3 presenting early, whereas patients with GI3 presenting late and treated with TT are at particular risk of reinfarction.
确定就诊时心电图的缺血分级（GI）和症状持续时间能否识别出在降低死亡率或再梗死方面，相较于接受溶栓治疗（TT）的ST段抬高型急性心肌梗死（STEMI）患者总体人群，能从直接经皮冠状动脉介入治疗（pPCI）中获益更多的患者亚组。
1319例丹麦急性心肌梗死试验-2（DANAMI-2）患者被分类为患有2级缺血（GI2；ST段抬高且无终末QRS波变形）或3级缺血（GI3；≥2个相邻导联出现ST段抬高且伴有终末QRS波变形），并根据从症状发作到治疗的中位时间（3小时）分为早期和晚期组。观察指标为30天死亡率和再梗死率。
GI3组的死亡率显著高于GI2组（9.7%对4.8%，p<0.001），晚期就诊患者的死亡率翻倍（GI2：6.0%对3.3%，p=0.01；GI3：12.5%对4.7%，p=0.05）。pPCI和TT的总体死亡率无显著差异；然而，早期接受pPCI治疗的GI3患者绝对死亡率降低了5.5%（1.4%对6.9%，p=0.10）。在晚期就诊且接受TT治疗的GI3患者中，再梗死率特别高（12.2%）。此类患者接受pPCI可显著降低再梗死率（0%，p<0.001）。逻辑回归分析显示，年龄（比值比（OR）1.09，95%置信区间（CI）1.06至1.12，p<0.001）、既往心绞痛（OR 2.56，95%CI 1.44至4.54，p=0.001）、心率（OR 1.03，95%CI 1.01至1.04，p=0.001）和GI3（OR 1.91，95%CI 1.06至3.44，p=0.031）与死亡率独立相关，而ST段抬高总和则不然。
GI3是STEMI患者死亡率的独立预测因素。GI2和GI3患者的死亡率均随症状持续时间显著增加。pPCI对早期就诊的GI3患者可能特别有益，而晚期就诊且接受TT治疗的GI3患者再梗死风险特别高。
