Rogers W J, Babb J D, Baim D S, Chesebro J H, Gore J M, Roberts R, Williams D O, Frederick M, Passamani E R, Braunwald E
University of Alabama Medical Center, Birmingham 35294.
J Am Coll Cardiol. 1991 Apr;17(5):1007-16. doi: 10.1016/0735-1097(91)90823-r.
To ascertain whether predischarge arteriography is beneficial in patients with acute myocardial infarction treated with recombinant tissue-type plasminogen activator (rt-PA), heparin and aspirin, the outcome of 197 patients in the Thrombolysis in Myocardial Infarction (TIMI) IIA study assigned to conservative management and routine predischarge coronary arteriography (routine catheterization group) was compared with the outcome of 1,461 patients from the TIMI IIB study assigned to conservative management without routine coronary arteriography unless ischemia recurred spontaneously or on predischarge exercise testing (selective catheterization group). The two groups were similar with regard to important baseline variables. During the initial hospital stay, coronary arteriography was performed in 93.9% of the routine catheterization group and 34.7% of the selective catheterization group (p less than 0.001), but the frequency of coronary revascularization (angioplasty or coronary artery bypass surgery) was similar in the two groups (24.4% versus 20.7%, p = NS). Coronary arteriograms showed a predominance of zero or one vessel disease (stenosis greater than or equal to 60%) in both groups (routine catheterization group 73.1%, selective catheterization group 61.3%). During the 1st year after infarction, rehospitalization for cardiac reasons and the interim performance of coronary arteriography were more common in the selective catheterization group (37.9% versus 27.6%, p = 0.007 and 28.6% versus 11.6%, p less than 0.001, respectively); however, the interim rates of death, nonfatal reinfarction and performance of coronary revascularization procedures were similar. At the end of 1 year, coronary arteriography had been performed one or more times in 98.9% of the routine catheterization group and 59.4% of the selective catheterization group (p less than 0.001), whereas death and nonfatal reinfarction had occurred in 10.2% versus 7.0% (p = 0.10) and 8.6% versus 9.0% (p = 0.87), respectively. Because the selective coronary arteriography policy exposes about 40% fewer patients to the small but finite risks and inconvenience of the procedure without compromising the 1 year survival or reinfarction rates, it seems to be an appropriate management strategy.
为确定出院前血管造影术对接受重组组织型纤溶酶原激活剂（rt - PA）、肝素和阿司匹林治疗的急性心肌梗死患者是否有益，将心肌梗死溶栓（TIMI）IIA研究中分配至保守治疗和常规出院前冠状动脉造影术组（常规导管插入术组）的197例患者的结局，与TIMI IIB研究中分配至保守治疗且除非缺血自发复发或出院前运动试验时才进行常规冠状动脉造影术组（选择性导管插入术组）的1461例患者的结局进行了比较。两组在重要的基线变量方面相似。在初次住院期间，常规导管插入术组93.9%的患者进行了冠状动脉造影术，选择性导管插入术组为34.7%（p < 0.001），但两组冠状动脉血运重建（血管成形术或冠状动脉搭桥手术）的频率相似（24.4%对20.7%，p = 无显著差异）。冠状动脉造影显示两组中零支或一支血管病变（狭窄≥60%）占主导（常规导管插入术组73.1%，选择性导管插入术组61.3%）。在心肌梗死后的第1年，选择性导管插入术组因心脏原因再次住院及进行冠状动脉造影术的中期情况更为常见（分别为37.9%对27.6%，p = 0.007以及28.6%对11.6%，p < 0.001）；然而，中期的死亡率、非致命性再梗死率及冠状动脉血运重建手术的实施率相似。在1年末，常规导管插入术组98.9%的患者进行了一次或多次冠状动脉造影术，选择性导管插入术组为59.4%（p < 0.001），而死亡率和非致命性再梗死率分别为10.2%对7.0%（p = 0.10）以及8.6%对9.0%（p = 0.87）。由于选择性冠状动脉造影术策略使接受该手术的小但有限的风险和不便的患者减少约40%，且不影响1年生存率或再梗死率，所以它似乎是一种合适的管理策略。
