Pinto Duane S, Kirtane Ajay J, Nallamothu Brahmajee K, Murphy Sabina A, Cohen David J, Laham Roger J, Cutlip Donald E, Bates Eric R, Frederick Paul D, Miller Dave P, Carrozza Joseph P, Antman Elliott M, Cannon Christopher P, Gibson C Michael
TIMI Study Group and the Cardiovascular Division, Department of Medicine, Beth Israel Deaconess Medical Center, 185 Pilgrim Rd, Boston, MA 02115, USA.
Circulation. 2006 Nov 7;114(19):2019-25. doi: 10.1161/CIRCULATIONAHA.106.638353. Epub 2006 Oct 30.
It has been suggested that the survival benefit associated with primary percutaneous coronary intervention (PPCI) in ST-segment elevation myocardial infarction may be attenuated if door-to-balloon (DB) time is delayed by >1 hour beyond door-to-needle (DN) times for fibrinolytic therapy. Whereas DB times are rapid in randomized trials, they are often prolonged in routine practice. We hypothesized that in clinical practice, longer DB-DN times would be associated with higher mortality rates and reduced PPCI survival advantage. We also hypothesized that in addition to PPCI delays, patient risk factors would significantly modulate the relative survival advantage of PPCI over fibrinolysis.
DB-DN times were calculated by subtracting median DN time from median DB time at a hospital using data from 192,509 patients at 645 National Registry of Myocardial Infarction hospitals. Hierarchical models that adjusted simultaneously for both patient-level risk factors and hospital-level covariates were used to evaluate the relationship between PCI-related delay, patient risk factors, and in-hospital mortality. Longer DB-DN times were associated with increased mortality (P<0.0001). The DB-DN time at which mortality rates with PPCI were no better than that of fibrinolysis varied considerably depending on patient age, symptom duration, and infarct location.
As DB-DN times increase, the mortality advantage of PPCI over fibrinolysis declines, and this advantage varies considerably depending on patient characteristics. As indicated in the American College of Cardiology/American Heart Association guidelines, both the hospital-based PPCI-related delay (DB-DN time) and patient characteristics should be considered when a reperfusion strategy is selected.
有人提出，如果在ST段抬高型心肌梗死中，门球时间（DB）比溶栓治疗的门针时间（DN）延迟超过1小时，那么与直接经皮冠状动脉介入治疗（PPCI）相关的生存获益可能会减弱。虽然在随机试验中DB时间较快，但在常规实践中往往会延长。我们假设，在临床实践中，较长的DB-DN时间将与较高的死亡率以及PPCI生存优势的降低相关。我们还假设，除了PPCI延迟外，患者风险因素会显著调节PPCI相对于溶栓治疗的相对生存优势。
利用645家国家心肌梗死注册医院的192,509例患者的数据，通过从一家医院的中位数DB时间中减去中位数DN时间来计算DB-DN时间。同时对患者层面的风险因素和医院层面的协变量进行调整的分层模型，用于评估PCI相关延迟、患者风险因素与住院死亡率之间的关系。较长的DB-DN时间与死亡率增加相关（P<0.0001）。PPCI死亡率不比溶栓治疗好的DB-DN时间因患者年龄、症状持续时间和梗死部位而异。
随着DB-DN时间增加，PPCI相对于溶栓治疗的死亡率优势下降，且这种优势因患者特征而异。正如美国心脏病学会/美国心脏协会指南所指出的，在选择再灌注策略时，应同时考虑基于医院的PPCI相关延迟（DB-DN时间）和患者特征。
