Gulba D C, Daniel W G, Simon R, Jost S, Barthels M, Amende I, Rafflenbeul W, Lichtlen P R
Division of Cardiology, Hannover Medical School, Federal Republic of Germany.
J Am Coll Cardiol. 1990 Sep;16(3):563-8. doi: 10.1016/0735-1097(90)90343-n.
In a series of 447 patients with single vessel angioplasty, 27 (6.0%) had acute thrombotic occlusion early after the procedure. They were treated with combined intracoronary (20 mg)/intravenous (50 mg) thrombolysis with recombinant tissue-type plasminogen activator (rt-PA) and repeat mild balloon inflations. Reopening of the vessel was achieved in 22 patients (81.5%). Follow-up coronary angiography 24 to 36 h later revealed reocclusion in 12 patients (54.5%). Thrombin levels measured as thrombin-antithrombin-III complex in patients with successful thrombolysis and persistent patency decreased from 8.5 +/- 11.4 micrograms/liter at baseline to 3.5 +/- 1.4 micrograms/liter 120 min after the start of thrombolysis; these levels increased from 9.4 +/- 15.0 micrograms/liter at baseline to 15.7 +/- 13.5 micrograms/liter 120 min after the start of thrombolysis in the patients with unsuccessful thrombolysis or early reocclusion (p less than 0.05). When a borderline value for thrombin-antithrombin-III complex level of 6 micrograms/liter was selected to separate the two groups of patients, patients with an unfavorable clinical course were identified 120 min after the start of thrombolysis by levels greater than 6 micrograms/liter (sensitivity 100%, specificity 92.8%). Thus, after abrupt thrombotic vessel closure during coronary angioplasty, the short-term results of thrombolysis seem to be governed by the release of thrombin. In two thirds of patients, however, the thrombin release cannot be suppressed by concomitant aspirin and heparin therapy. Even after successful reopening of the vessel these patients should therefore undergo immediate aortocoronary bypass grafting.
在447例行单支血管成形术的患者中，27例（6.0%）在术后早期发生急性血栓闭塞。他们接受了冠状动脉内（20 mg）/静脉内（50 mg）联合使用重组组织型纤溶酶原激活剂（rt-PA）溶栓及重复轻度球囊扩张治疗。22例患者（81.5%）血管重新开通。24至36小时后的随访冠状动脉造影显示，12例患者（54.5%）再次闭塞。成功溶栓且血管持续通畅患者的凝血酶水平以凝血酶 - 抗凝血酶 - III复合物测定，从基线时的8.5±11.4微克/升降至溶栓开始后120分钟时的3.5±1.4微克/升；溶栓失败或早期再闭塞患者的这些水平从基线时的9.4±15.0微克/升升至溶栓开始后120分钟时的15.7±13.5微克/升（p<0.05）。当选择凝血酶 - 抗凝血酶 - III复合物水平的临界值6微克/升来区分两组患者时，溶栓开始后120分钟时，复合物水平大于6微克/升的患者被判定为临床病程不佳（敏感性100%，特异性92.8%）。因此，冠状动脉成形术中出现急性血栓性血管闭塞后，溶栓的短期效果似乎受凝血酶释放的支配。然而，在三分之二的患者中，阿司匹林和肝素联合治疗无法抑制凝血酶释放。因此，即使血管成功重新开通，这些患者也应立即接受主动脉冠状动脉旁路移植术。
