Brodie B R, Weintraub R A, Stuckey T D, LeBauer E J, Katz J D, Kelly T A, Hansen C J
Department of Medicine, Moses H. Cone Memorial Hospital, Greensboro, North Carolina.
Am J Cardiol. 1991 Jan 1;67(1):7-12. doi: 10.1016/0002-9149(91)90090-8.
Coronary angioplasty without prior thrombolytic therapy was performed in 383 patients with acute myocardial infarction (AMI). Patients were divided into 2 groups depending on whether they were candidates or non-candidates for thrombolytic therapy. Patients were not considered thrombolytic candidates if they: (1) presented in cardiogenic shock, (2) were greater than or equal to 75 years of age, (3) had had coronary artery bypass surgery or, (4) had a reperfusion time of greater than 6 hours. Thrombolytic and nonthrombolytic candidates had similar rates of reperfusion (92 vs 88%), nonfatal reinfarction (6.0 vs 5.9%) and recurrent myocardial ischemia (1.8 vs 0%). Thrombolytic candidates had a lower mortality rate (3.9 vs 24%, p less than 0.0001) and a lower incidence of bleeding (4.6 vs 10.9%, p less than 0.05). Improvement in left ventricular ejection fraction at follow-up angiography was 4.4% in thrombolytic and 10.5% in nonthrombolytic candidates (p less than 0.002). Ejection fraction improved most in patients with anterior wall AMI (7.7% in thrombolytic candidates, 15.1% in nonthrombolytic candidates) and in patients with reperfusion times greater than 6 hours (14.2%). These outcomes suggest that direct coronary angioplasty is a viable alternative method of reperfusion in patients with AMI who are candidates for thrombolytic therapy. Nonthrombolytic candidates are a high-risk group of patients. Direct coronary angioplasty may be beneficial in certain subgroups, especially for patients in cardiogenic shock and for patients presenting greater than 6 hours after the onset of chest pain with evidence of ongoing ischemia.
对383例急性心肌梗死（AMI）患者进行了未先行溶栓治疗的冠状动脉血管成形术。根据患者是否适合溶栓治疗，将其分为两组。若患者存在以下情况，则不被视为溶栓治疗候选者：（1）出现心源性休克；（2）年龄大于或等于75岁；（3）曾接受冠状动脉搭桥手术；（4）再灌注时间大于6小时。溶栓治疗候选者和非溶栓治疗候选者的再灌注率相似（分别为92%和88%）、非致死性再梗死率相似（分别为6.0%和5.9%）以及复发性心肌缺血发生率相似（分别为1.8%和0%）。溶栓治疗候选者的死亡率较低（分别为3.9%和24%，p<0.0001），出血发生率也较低（分别为4.6%和10.9%，p<0.05）。随访血管造影显示，溶栓治疗候选者左心室射血分数提高了4.4%，非溶栓治疗候选者提高了10.5%（p<0.002）。前壁AMI患者（溶栓治疗候选者提高7.7%，非溶栓治疗候选者提高15.1%）以及再灌注时间大于6小时的患者（提高14.2%）的射血分数改善最为明显。这些结果表明，对于适合溶栓治疗的AMI患者，直接冠状动脉血管成形术是一种可行的再灌注替代方法。非溶栓治疗候选者是高危患者群体。直接冠状动脉血管成形术可能对某些亚组有益，尤其是心源性休克患者以及胸痛发作后6小时以上出现持续缺血证据的患者。
