Cardiology Department, and University of New South Wales, Liverpool Hospital, Sydney, Australia.
Am Heart J. 2011 Jul;162(1):89-97. doi: 10.1016/j.ahj.2011.04.009.
Mortality after ST-elevation myocardial infarction (STEMI) has reduced with reperfusion by primary percutaneous coronary intervention (PCI), which may have impacted on the adverse outcomes of cardiogenic shock (CS) and congestive heart failure (CHF).
In the APEX-AMI trial, 5,745 patients with STEMI and planned primary PCI were randomly assigned pexelizumab or matching placebo. Post-randomization CS or CHF was adjudicated by a clinical endpoints committee. Treatment assignment to pexelizumab did not influence either endpoint or mortality rates. Cardiogenic shock developed in 196 patients (3.4%) at a median of 6.0 hours (interquartile range 3.9-28.3) post-randomization, and mortality at 90 days was 54.6%. Congestive heart failure occurred in 254 of patients (4.4%) at a median of 2.6 days (IQR 1.0-16.6), and mortality through 90 days was 10.2%; mortality among those with neither endpoint was 2.1%. Patients with CS or CHF were older, were more often female, and had more hypertension and diabetes, but smoked less compared with non-CS/CHF patients (all P < .05). Independent mortality predictors among those with CS or CHF were hyperlipidemia and a history of angina (interaction P = .011 and .008, respectively); procedural predictors among survivors to PCI were pre-PCI Thrombolysis In Myocardial Infarction (TIMI) flow 0-1 and post-PCI TIMI flow <3 (P = .013 and <.0001, respectively).
Survival after CS remains poor despite aggressive reperfusion. Both CS and CHF remain the major causes of death among STEMI patients undergoing primary PCI. Future studies should examine treatments that aim to reduce mortality in these highest risk patients.
ST 段抬高型心肌梗死（STEMI）经直接经皮冠状动脉介入治疗（PCI）再灌注后死亡率降低，这可能对心源性休克（CS）和充血性心力衰竭（CHF）的不良结局产生影响。
在 APEX-AMI 试验中，5745 例 STEMI 患者计划进行直接 PCI，随机分为接受培昔单抗或匹配安慰剂治疗。通过临床终点委员会对随机分组后 CS 或 CHF 进行判定。培昔单抗的治疗分配并未影响任一终点或死亡率。196 例患者（3.4%）在随机分组后中位 6.0 小时（四分位距 3.9-28.3）发生心源性休克，90 天死亡率为 54.6%。254 例患者（4.4%）发生充血性心力衰竭，中位时间为 2.6 天（IQR 1.0-16.6），90 天死亡率为 10.2%；无终点患者死亡率为 2.1%。心源性休克或充血性心力衰竭患者年龄较大，女性更多，高血压和糖尿病更多，但吸烟较少（所有 P<0.05）。心源性休克或充血性心力衰竭患者的独立死亡率预测因素为血脂异常和心绞痛史（交互 P 值分别为.011 和.008）；PCI 后存活患者的预测因素为 PCI 前 Thrombolysis In Myocardial Infarction（TIMI）血流 0-1 和 PCI 后 TIMI 血流<3（P 值分别为.013 和<.0001）。
尽管进行了积极的再灌注，CS 后的生存率仍然很差。CS 和 CHF 仍然是 STEMI 患者行直接 PCI 后死亡的主要原因。未来的研究应探讨旨在降低这些高危患者死亡率的治疗方法。
