Dudek Dariusz, Rakowski Tomasz, El Massri Nader, Sorysz Danuta, Zalewski Jaroslaw, Legutko Jacek, Dziewierz Artur, Rzeszutko Lukasz, Zmudka Krzysztof, Piwowarska Wieslawa, De Luca Giuseppe, Kaluza Grzegorz L, Janion Marianna, Dubiel Jacek S
2nd Department of Cardiology, Institute of Cardiology, Jagiellonian University Medical College, Krakow, Poland.
Int J Cardiol. 2008 Mar 14;124(3):326-31. doi: 10.1016/j.ijcard.2007.02.008. Epub 2007 Apr 12.
Time-to-treatment is an important determinant of mortality in primary angioplasty for ST-segment elevation myocardial infarction (STEMI). Thus, the benefits in outcome observed with transferring for primary angioplasty in comparison with on-site thrombolysis may be reduced or even lost when long-distance transportation is required. Even though pharmacological reperfusion might overcome this limitation, no data have been reported so far on the prognostic role of early pharmacological recanalization in STEMI patients undergoing long-distance transportation for primary angioplasty.
We enrolled 225 consecutive STEMI patients without shock, eligible for thrombolysis, with at least 90-minute transport time to our primary PCI center. During transport, patients received i.v. heparin 40 U/kg, alteplase 15 mg+35 mg infusion and abciximab 0.25 mg/kg+0.125 microg/kg/min infusion for 12 h.
Patients were divided into two groups according baseline angiography, which showed early pharmacological reperfusion (preprocedural TIMI flow 2+3) in 193 patients (85.8%) and no reperfusion (preprocedural TIMI flow 0+1) in 32 patients (14.2%). Despite no difference in postprocedural TIMI flow, early reperfusion was associated with better postprocedural myocardial perfusion (TMPG 3: 54.9% vs. 18.7%, p<0.0001), better improvement in left ventricular ejection fraction (LVEF) (from 55.6+/-8.6% to 58.8+/-10.4% p<0.001 with early reperfusion vs. 52.9+/-13.4% to 50.4+/-15.8% with no early reperfusion, p=NS) and 1-year outcome (p=0.002 log rank). In multivariate analysis, preprocedural TIMI flow 0+1 independently predicted death and reinfarction at 1 year, and lack of LVEF improvement at 6 months.
Early pharmacological reperfusion in STEMI patients undergoing long-distance transportation for primary angioplasty is associated with better postprocedural myocardial perfusion, better LVEF recovery at 6 months and improved 1-year clinical outcome.
治疗时间是ST段抬高型心肌梗死（STEMI）直接血管成形术死亡率的重要决定因素。因此，当需要长途转运时，与就地溶栓相比，直接血管成形术在转院治疗中所观察到的预后益处可能会减少甚至丧失。尽管药物再灌注可能克服这一限制，但目前尚无关于早期药物再灌注在接受长途转运以进行直接血管成形术的STEMI患者中的预后作用的数据报道。
我们连续纳入了225例无休克、符合溶栓条件、转运至我们的直接PCI中心至少需要90分钟的STEMI患者。在转运过程中，患者接受静脉注射肝素40 U/kg、阿替普酶15 mg + 35 mg静脉滴注以及阿昔单抗0.25 mg/kg + 0.125 μg/kg/min静脉滴注，持续12小时。
根据基线血管造影将患者分为两组，193例患者（85.8%）显示早期药物再灌注（术前TIMI血流2 + 3级），32例患者（14.2%）未再灌注（术前TIMI血流0 + 1级）。尽管术后TIMI血流无差异，但早期再灌注与更好的术后心肌灌注相关（心肌灌注分级3级：54.9% 对18.7%，p < 0.0001），左心室射血分数（LVEF）改善更好（早期再灌注组从55.6 ± 8.6% 提高到58.8 ± 10.4%，p < 0.001；未早期再灌注组从52.9 ± 13.4% 降至50.4 ± 15.8%，p = 无显著性差异）以及1年预后更好（p = 0.002，对数秩检验）。在多变量分析中，术前TIMI血流0 + 1级独立预测1年时的死亡和再梗死，以及6个月时LVEF无改善。
接受长途转运以进行直接血管成形术的STEMI患者早期药物再灌注与更好的术后心肌灌注、6个月时更好的LVEF恢复以及改善的1年临床结局相关。
