Ruff Christian T, Wiviott Stephen D, Morrow David A, Mohanavelu Satishkumar, Murphy Sabina A, Antman Elliott M, Braunwald Eugene
TIMI Study Group, Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass 02115, USA.
Am J Med. 2007 Nov;120(11):993-8. doi: 10.1016/j.amjmed.2007.08.020.
The purpose of the study was to evaluate the cause of death, risk of nonfatal complications, and relative outcomes with an enoxaparin versus unfractionated heparin strategy in ST-elevation myocardial infarction stratified using the Thrombolysis in Myocardial Infarction (TIMI) Risk Index (TRI).
We evaluated 30-day outcomes in 19,941 patients with ST-elevation myocardial infarction treated with fibrinolysis and unfractionated heparin or enoxaparin. Patients were categorized on the basis of prespecified ranges of the TRI [heart rate x (age/10)2/systolic blood pressure].
There was a strongly graded increase in 30-day mortality with increasing TRI (1.2%-20.7%, P<.0001). The proportion of deaths due to mechanical causes (congestive heart failure, shock, and myocardial rupture) increased progressively with the TRI. There also was a significant positively graded association between the TRI and nonfatal heart failure or shock (0.4%-4.4%, P<.0001). In contrast, death resulting from recurrent ischemic events predominated in the lowest TRI group. The relative reduction in death/myocardial infarction with the enoxaparin strategy appeared inversely graded with the TRI. There was a 38% reduction in the lowest risk group (relative risk 0.62, 95% confidence interval 0.45-0.86) and a decrease in the relative benefit of enoxaparin with increasing risk index.
The TRI was a strong predictor of all-cause mortality in a broad population, with a positive association with the risk of death due to mechanical complications and an inverse association with deaths due to recurrent ischemia. The enoxaparin strategy was superior to unfractionated heparin in a majority of patients with ST-elevation myocardial infarction, except for the group at the highest risk for severe mechanical complications, in whom the 2 anticoagulant strategies showed similar results.
本研究旨在评估ST段抬高型心肌梗死患者采用依诺肝素与普通肝素治疗策略时，使用心肌梗死溶栓（TIMI）风险指数（TRI）进行分层后的死亡原因、非致命并发症风险及相对转归情况。
我们评估了19941例接受纤溶治疗及普通肝素或依诺肝素治疗的ST段抬高型心肌梗死患者的30天转归情况。患者根据预先设定的TRI范围[心率×（年龄/10）²/收缩压]进行分类。
随着TRI升高，30天死亡率呈显著的梯度性增加（1.2% - 20.7%，P<0.0001）。机械性原因（充血性心力衰竭、休克和心肌破裂）导致的死亡比例随TRI逐渐增加。TRI与非致命性心力衰竭或休克之间也存在显著的正性梯度关联（0.4% - 4.4%，P<0.0001）。相比之下，最低TRI组中复发性缺血事件导致的死亡占主导。依诺肝素治疗策略导致的死亡/心肌梗死相对降低似乎与TRI呈反向梯度关系。最低风险组降低了38%（相对风险0.62，95%置信区间0.45 - 0.86），且随着风险指数增加，依诺肝素的相对获益减少。
TRI是广泛人群全因死亡率的有力预测指标，与机械性并发症导致的死亡风险呈正相关，与复发性缺血导致的死亡呈负相关。在大多数ST段抬高型心肌梗死患者中，依诺肝素治疗策略优于普通肝素，但在严重机械性并发症风险最高的组中，两种抗凝策略结果相似。
