Kuch B, Heier M, von Scheidt W, Kling B, Hoermann A, Meisinger C
I. Medizinische Klinik, Hospital of Augsburg, Teaching Hospital of the Ludwig Maximilians University München, Augsburg, Germany.
J Intern Med. 2008 Sep;264(3):254-64. doi: 10.1111/j.1365-2796.2008.01956.x. Epub 2008 Apr 4.
To examine the extent to which evidence-based beneficial therapy is applied in practice, whether this is changing over time and is associated with improved outcomes.
Randomized trials have proved efficacy of several treatments for acute myocardial infarction (AMI) with ST-elevation (STEMI), non-ST-elevation (NSTEMI) and bundle branch block (BBB).
We prospectively examined all 6748 consecutive patients with AMI aged 25-74 years hospitalized in the study region's major clinic stratified into four time-periods: 1985-1989 (n = 1622), 1990-1994 (n = 1588), 1995-1999 (n = 1450) and 2000-2004 (n = 2088).
The increase in numbers of AMI in the last period was mainly, but not exclusively driven by NSTEMI cases. Evidence-based pharmacological therapy increased steeply over time. Invasive procedures increased mainly in the last period with percutaneous coronary intervention and coronary artery bypass graft performed in 30% and 15% in 1998 and 66.0% and 22%, respectively, in 2004. In-hospital complications and 28-day-case fatality decreased significantly from period 1 to period 4 in all patients with AMI. Marked reductions in 28-day-case fatality were mostly seen in BBB patients during the last period (25.3% vs. 10.3%, P < 0.001). Of interest, the odds in 28-day-case fatality reduction was diminished after correction for recanalization therapy (from 0.35, 95% CI: 0.16-0.74 to 0.52, 95% CI: 0.19-1.45).
Over the past 20 years, there were substantial changes in pharmacological and interventional therapies in AMI accompanied by reductions in in-hospital complications and 28-day-case fatality in all infarction types with marked reductions in 28-day-case fatality in BBB patients. The latter observation may mainly be because of the increased use of interventional therapy.
探讨循证有益治疗在实际应用中的程度，其是否随时间变化以及与改善的预后相关。
随机试验已证实几种治疗方法对ST段抬高型急性心肌梗死（AMI）、非ST段抬高型急性心肌梗死（NSTEMI）和束支传导阻滞（BBB）有效。
我们前瞻性地研究了在研究区域主要诊所住院的所有6748例年龄在25 - 74岁的连续AMI患者，分为四个时间段：1985 - 1989年（n = 1622）、1990 - 1994年（n = 1588）、1995 - 1999年（n = 1450）和2000 - 2004年（n = 2088）。
最后一个时间段AMI病例数的增加主要但并非仅由NSTEMI病例驱动。循证药物治疗随时间急剧增加。侵入性操作主要在最后一个时间段增加，1998年经皮冠状动脉介入治疗和冠状动脉旁路移植术的实施率分别为30%和15%，2004年分别为66.0%和22%。所有AMI患者的院内并发症和28天病例死亡率从第1阶段到第4阶段显著降低。在最后一个时间段，BBB患者的28天病例死亡率显著降低（25.3%对10.3%，P < 0.001）。有趣的是，在对再灌注治疗进行校正后，28天病例死亡率降低的优势比减小（从0.35，95%CI：0.16 - 0.74变为0.52，95%CI：0.19 - 1.45）。
在过去20年中，AMI的药物和介入治疗有实质性变化，同时所有梗死类型的院内并发症和28天病例死亡率降低，BBB患者的28天病例死亡率显著降低。后一观察结果可能主要是由于介入治疗的使用增加。
