Timmer Jorik R, Ottervanger Jan Paul, de Boer Menko-Jan, Boersma Eric, Grines Cindy L, Westerhout Cynthia M, Simes R John, Granger Christopher B, Zijlstra Felix
Department of Cardiology, Isala Klinieken, Groot Wezenland 20, 8011 JW Zwolle, the Netherlands.
Arch Intern Med. 2007 Jul 9;167(13):1353-9. doi: 10.1001/archinte.167.13.1353.
There is growing evidence for a clinical benefit of primary percutaneous coronary intervention (PCI) compared with fibrinolysis; however, whether the treatment effect is consistent among patients with diabetes mellitus is unclear. We compared PCI with fibrinolysis for treatment of ST-segment elevation myocardial infarction in patients with diabetes mellitus.
A pooled analysis of individual patient data from 19 trials comparing primary PCI with fibrinolysis for treatment of ST-segment elevation myocardial infarction was performed. Trials that enrolled at least 50 patients with ST-segment elevation myocardial infarction and randomized patients to receive either primary PCI or fibrinolysis were considered for inclusion in our study. Clinical end points were total deaths, recurrent infarction, death or nonfatal recurrent infarction, and stroke, measured 30 days after randomization.
Of 6315 patients, 877 (14%) had diabetes. Thirty-day mortality (9.4% vs 5.9%; P < .001) was higher in patients with diabetes. Mortality was lower after primary PCI compared with fibrinolysis in both patients with diabetes (unadjusted odds ratio, 0.49; 95% confidence interval, 0.31-0.79; P = .004) and without diabetes (unadjusted odds ratio, 0.69; 95% confidence interval, 0.54-0.86, P = .001), with no evidence of heterogeneity of treatment effect (P = .24 for interaction). Recurrent infarction and stroke were also reduced after primary PCI in both patient groups. After multivariable analysis, primary PCI was associated with decreased 30-day mortality in patients with and without diabetes, with a point estimate of greater benefit in diabetic patients.
Diabetic patients with ST-segment elevation myocardial infarction treated with reperfusion therapy have increased mortality compared with patients without diabetes. The beneficial effects of primary PCI compared with fibrinolysis in diabetic patients are consistent with effects in nondiabetic patients.
与纤溶治疗相比，越来越多的证据表明直接经皮冠状动脉介入治疗（PCI）具有临床益处；然而，在糖尿病患者中治疗效果是否一致尚不清楚。我们比较了PCI与纤溶治疗糖尿病患者ST段抬高型心肌梗死的疗效。
对19项比较直接PCI与纤溶治疗ST段抬高型心肌梗死的试验的个体患者数据进行汇总分析。纳入至少50例ST段抬高型心肌梗死患者并将患者随机分组接受直接PCI或纤溶治疗的试验。临床终点为随机分组30天后的全因死亡、再发梗死、死亡或非致死性再发梗死以及卒中。
6315例患者中，877例（14%）患有糖尿病。糖尿病患者30天死亡率更高（9.4%对5.9%；P<0.001）。在糖尿病患者（未调整优势比，0.49；95%置信区间，0.31 - 0.79；P = 0.004）和非糖尿病患者（未调整优势比，0.69；95%置信区间，0.54 - 0.86，P = 0.001）中，直接PCI后的死亡率均低于纤溶治疗，且无治疗效果异质性的证据（交互作用P = 0.24）。两组患者直接PCI后再发梗死和卒中也有所减少。多变量分析后，直接PCI与糖尿病患者和非糖尿病患者30天死亡率降低相关，点估计显示对糖尿病患者的益处更大。
与非糖尿病患者相比，接受再灌注治疗的糖尿病ST段抬高型心肌梗死患者死亡率更高。与纤溶治疗相比，直接PCI对糖尿病患者的有益效果与非糖尿病患者一致。
