Kunadian Babu, Vijayalakshmi Kunadian, Dunning Joel, Sutton Andrew, de Belder Mark A
Department of Cardiology, The James Cook University Hospital, Middlesbrough, United Kingdom.
J Invasive Cardiol. 2007 Sep;19(9):359-68.
The large randomized trials on rescue angioplasty (rPCI) have been interpreted by some as showing differing results. We compared the protocols, demographics and 6-month clinical outcomes of the MERLIN trial with the RESCUE I and REACT trials to assess their differences.
The RESCUE I trial did not involve the use of stenting or glycoprotein IIb/IIIa inhibitors, and patients with previous MI were excluded. The recruitment rate in MERLIN was 30.7 patients per center per year vs. 3.3 in REACT and 2.4 in the RESCUE I trial. The patients in the MERLIN trial were older. Streptokinase was used more commonly in the MERLIN trial: 96% vs. 60% in REACT. In the rPCI arm, pain onset to lysis time was longer, 180 vs. 140 minutes in MERLIN, but lysis to angiography (146 vs. 274 minutes) and pain onset to angiography (327 vs. 414 minute) times were shorter compared with the REACT trial. In the rPCI arms, mortality at 6 months was lower in the REACT trial than in the MERLIN trial although the difference was not statistically significant. This numeric difference in mortality is unlikely to be explained by the differences in the use of glycoprotein IIb/IIIa inhibitors or stenting. In the rPCI arms, reinfarction rates were higher in the MERLIN trial (7.8% vs. 2.1%), possibly due to lower rates of stenting (50.3% vs. 68.5%) and less use of glycoprotein IIb/IIIa inhibitors (3.3% vs. 43.4%). The three trials used different definitions of heart failure, with a trend towards a reduction in heart failure in all three studies.
These trials differ in various aspects. The RESCUE I trial enrolled lower-risk patients than the MERLIN trial and was done without the use of stents and glycoprotein IIb/IIIa inhibitors. The MERLIN trial is widely applicable to patients receiving streptokinase and had no age limit. REACT patients were younger and were enrolled more selectively. Although some outcomes were similar, differences in patient recruitment and protocols may have accounted for the numerical difference in mortality rates at 6 months in the MERLIN and REACT trials. Meta-analysis suggests an overall clinical benefit from rescue PCI (lower mortality, less reinfarction and less heart failure) at the expense of an increased risk of stroke and bleeding.
一些人对关于补救性血管成形术（rPCI）的大型随机试验结果的解读存在差异。我们比较了MERLIN试验与RESCUE I和REACT试验的方案、人口统计学特征及6个月的临床结局，以评估它们之间的差异。
RESCUE I试验未使用支架或糖蛋白IIb/IIIa抑制剂，且排除了既往有心肌梗死的患者。MERLIN试验的入组率为每个中心每年30.7例患者，而REACT试验为3.3例，RESCUE I试验为2.4例。MERLIN试验中的患者年龄更大。MERLIN试验中更常使用链激酶：分别为96%和60%。在rPCI组中，MERLIN试验从疼痛发作到溶栓的时间更长，为180分钟，而REACT试验为140分钟，但与REACT试验相比，MERLIN试验从溶栓到血管造影（146分钟对274分钟）以及从疼痛发作到血管造影（327分钟对414分钟）的时间更短。在rPCI组中，REACT试验6个月时的死亡率低于MERLIN试验，尽管差异无统计学意义。死亡率的这种数值差异不太可能由糖蛋白IIb/IIIa抑制剂或支架使用的差异来解释。在rPCI组中，MERLIN试验的再梗死率更高（7.8%对2.1%），这可能是由于支架置入率较低（50.3%对68.5%）以及糖蛋白IIb/IIIa抑制剂的使用较少（3.3%对43.4%）。这三项试验对心力衰竭的定义不同，三项研究均有心力衰竭减轻的趋势。
这些试验在多个方面存在差异。RESCUE I试验纳入的患者风险低于MERLIN试验，且试验过程未使用支架和糖蛋白IIb/IIIa抑制剂。MERLIN试验广泛适用于接受链激酶治疗的患者，且无年龄限制。REACT试验的患者更年轻，入组更具选择性。尽管一些结局相似，但患者招募和方案的差异可能是MERLIN试验和REACT试验6个月时死亡率数值差异的原因。荟萃分析表明，补救性PCI总体上具有临床益处（降低死亡率、减少再梗死和减轻心力衰竭），但代价是中风和出血风险增加。
