Cragg D R, Friedman H Z, Bonema J D, Jaiyesimi I A, Ramos R G, Timmis G C, O'Neill W W, Schreiber T L
William Beaumont Hospital, Royal Oak, Michigan.
Ann Intern Med. 1991 Aug 1;115(3):173-7. doi: 10.7326/0003-4819-115-3-173.
To determine what proportion of patients with acute myocardial infarction are not eligible for thrombolytic therapy and to assess their natural history.
Retrospective chart review.
A large community-based hospital.
All patients with acute myocardial infarction hospitalized during a 27-month period.
Of 1471 patients with acute myocardial infarction, 230 (16%) received thrombolytic therapy according to the protocol and an additional 97 (7%) received nonprotocol thrombolytic therapy, primary coronary balloon angioplasty, or both because of contraindications. The other 1144 patients (78%) did not receive reperfusion therapy.
The patients who did not receive thrombolytic therapy were older, more likely to be women, and more likely to have a history of hypertension, previous myocardial infarction, or chronic angina (all comparisons, P less than 0.002). An average of 1.9 reasons for exclusion were identified per patient among the ineligible patients. Mortality was fivefold higher among ineligible patients (19%; Cl, 16% to 21%) than among protocol-treated patients (4%; Cl, 1% to 6%) (P less than 0.001). In-hospital mortality rates for excluded patients were 28% (Cl, 23% to 32%) in elderly patients (age, greater than 76 years; n = 396); 29% (Cl, 23% to 35%) in patients with stroke or bleeding risk (n = 209); 17% (Cl, 14% to 20%) in patients with delayed presentation (greater than 4 hours after the onset of chest pain; [n = 599]); 14% (Cl, 11% to 16%) in patients with an ineligible electrocardiogram (ECG) (n = 673); and 26% (Cl, 21% to 32%) in patients with a miscellaneous reason for exclusion (n = 243). Independent predictors of increased mortality were: age greater than 76 years, stroke or other bleeding risk, ineligible ECG, or the presence of two or more exclusion criteria.
Thrombolytic therapy is currently used in the United States for only a minority of patients with acute myocardial infarction: those who have low-risk prognostic characteristics.
确定急性心肌梗死患者中不符合溶栓治疗条件的患者比例，并评估其自然病程。
回顾性病历审查。
一家大型社区医院。
在27个月期间住院的所有急性心肌梗死患者。
在1471例急性心肌梗死患者中，230例（16%）按照方案接受了溶栓治疗，另外97例（7%）因禁忌证接受了非方案溶栓治疗、冠状动脉球囊成形术或两者兼而有之。其余1144例患者（78%）未接受再灌注治疗。
未接受溶栓治疗的患者年龄更大，女性更多，更有可能有高血压、既往心肌梗死或慢性心绞痛病史（所有比较，P<0.002）。在不符合条件的患者中，每位患者平均确定1.9个排除原因。不符合条件的患者死亡率（19%；可信区间，16%至21%）是接受方案治疗患者（4%；可信区间，1%至6%）的五倍（P<0.001）。排除患者的住院死亡率在老年患者（年龄大于76岁；n = 396）中为28%（可信区间，23%至32%）；在有中风或出血风险的患者（n = 209）中为29%（可信区间，23%至35%）；在就诊延迟的患者（胸痛发作后大于4小时；[n = 599]）中为17%（可信区间，14%至20%）；在心电图（ECG）不符合条件的患者（n = 673）中为14%（可信区间，11%至16%）；在有其他排除原因的患者（n = 243）中为26%（可信区间，21%至32%）。死亡率增加的独立预测因素为：年龄大于76岁、中风或其他出血风险、心电图不符合条件或存在两个或更多排除标准。
目前在美国，溶栓治疗仅用于少数急性心肌梗死患者：即那些具有低风险预后特征的患者。
