Arntz H R, Mochmann H C
Medinzinische Klinik II, Kardiologie/Pulmologie, Charité – Universitätsmedizin, Campus Benjamin Franklin, Hindenburgdamm 30, 12200 Berlin.
Dtsch Med Wochenschr. 2010 Nov;135(47):2372-4. doi: 10.1055/s-0030-1269404. Epub 2010 Nov 16.
The introduction of intravenous thrombolytic therapy started the new era of reperfusion therapy in ST elevation myocardial infarction. The addition of aspirin almost halved mortality in patients with ST elevation infarction. Primary coronary intervention (PCI) often in combination with stent implantation instead of thrombolytic therapy increases infracted-artery patency and reduces mortality, number of re-infarction and stroke even further. However, studies comparing the benefits of both therapeutic regimens often included patients with long symptom duration (up to 12 hours and more). In addition, there are differences in long term treatment after myocardial infarction in both groups since the addition of thienopyridines to standard treatment after stent implantation. The routine combination of thrombolytic therapy and immediate PCI (facilitated PCI) did not prove beneficial whereas a pharamacoinvasive strategy including thrombolytic therapy and PCI at a later time point could be beneficial. Subgroup analysis in the studies comparing PCI and thrombolytic therapy suggested a beneficial effect for patients receiving thrombolytic therapy early after symptom onset (≥ 2 h). Therefore, a strategic concept of thrombolytic therapy early after symptom onset in patients presenting with ST elevation myocardial infarction combined with either rescue intervention when indicated or planned PCI is currently tested in the so STREAM-study (STrategic Reperfusion Early After Myocardial Infarction). Hopefully this study will clarify the role of thrombolytic therapy in ST Elevation myocardial infarction compared to PCI alone.
静脉溶栓治疗的引入开启了ST段抬高型心肌梗死再灌注治疗的新时代。阿司匹林的添加几乎使ST段抬高型梗死患者的死亡率减半。常与支架植入联合使用的直接冠状动脉介入治疗（PCI）而非溶栓治疗可提高梗死动脉通畅率，并进一步降低死亡率、再梗死次数和中风发生率。然而，比较两种治疗方案益处的研究通常纳入症状持续时间较长（长达12小时及以上）的患者。此外，由于支架植入后在标准治疗中添加噻吩吡啶，两组心肌梗死后的长期治疗存在差异。溶栓治疗与即刻PCI（易化PCI）的常规联合未被证明有益，而包括溶栓治疗和后期PCI的药物介入策略可能有益。比较PCI和溶栓治疗的研究中的亚组分析表明，症状发作后早期（≥2小时）接受溶栓治疗的患者有获益。因此，目前在STREAM研究（心肌梗死后早期战略再灌注）中正在测试一种针对ST段抬高型心肌梗死患者症状发作后早期溶栓治疗的策略概念，该策略结合了必要时的补救干预或计划性PCI。希望这项研究将阐明与单独PCI相比，溶栓治疗在ST段抬高型心肌梗死中的作用。
