White Harvey D, Chew Derek P
Green Lane Cardiovascular Service, Auckland City Hospital, Auckland, New Zealand.
Lancet. 2008 Aug 16;372(9638):570-84. doi: 10.1016/S0140-6736(08)61237-4.
Modern management of acute myocardial infarction is built on a clinical evidence base drawn from many studies undertaken over the past three decades. The evolution in clinical practice has substantially reduced mortality and morbidity associated with the condition. Key to this success is the effective integration of antithrombotic therapy combined with timely reperfusion, either primary percutaneous coronary intervention or fibrinolysis for ST-elevation myocardial infarction, and invasive investigation and revascularisation for non-ST-elevation myocardial infarction, underpinned by risk stratification and optimised systems of care. After the development of troponin assays for the detection of myonecrosis, the universal definition and classification of myocardial infarction now indicates the underlying pathophysiology. Additionally, an increasing appreciation of the importance of adverse events, such as bleeding, has emerged. Remaining challenges include the effective translation of this evidence to all patients with myocardial infarction, especially to those not well represented in clinical trials who remain at increased risk of adverse events, such as elderly patients and those with renal failure. On a global level, the epidemic of diabetes and obesity in the developed world and the transition from infectious diseases to cardiovascular disease in the developing world will place an increasing demand on health-care infrastructures required to deliver time-dependent and resource-intensive care. This Seminar discusses the underlying pathophysiology, evolving perspectives on diagnosis, risk stratification, and the invasive and pharmacological management of myocardial infarction.
急性心肌梗死的现代管理基于过去三十年开展的众多研究所形成的临床证据基础。临床实践的演变已大幅降低了与该病症相关的死亡率和发病率。这一成功的关键在于抗栓治疗与及时再灌注的有效整合，对于ST段抬高型心肌梗死采用直接经皮冠状动脉介入治疗或溶栓治疗，对于非ST段抬高型心肌梗死采用有创检查和血运重建，并以风险分层和优化的护理系统为支撑。在用于检测心肌坏死的肌钙蛋白检测方法发展之后，心肌梗死的通用定义和分类如今表明了潜在的病理生理学。此外，人们对诸如出血等不良事件的重要性的认识也在不断提高。尚存的挑战包括将这些证据有效地应用于所有心肌梗死患者，尤其是那些在临床试验中代表性不足、不良事件风险仍然增加的患者，如老年患者和肾衰竭患者。在全球层面，发达国家糖尿病和肥胖症的流行以及发展中国家从传染病向心血管疾病的转变，将对提供依赖时间和资源密集型护理所需的医疗保健基础设施提出越来越高的要求。本次研讨会讨论了心肌梗死的潜在病理生理学、不断演变的诊断观点、风险分层以及侵入性和药物治疗管理。
