Ellis S G
Department of Internal Medicine, University of Michigan Medical Center, Ann Arbor.
Circulation. 1990 Mar;81(3 Suppl):IV43-50.
Results of multiple studies have amply verified the benefit of urgent coronary revascularization for patients who have acute myocardial infarction (MI). Currently, intravenous thrombolytic therapy is the treatment of choice for many patients, especially those 75 years old or younger who present within 6 hours of symptom onset and who are without contraindications to thrombolytic therapy. Some patients treated within 6-24 hours of symptom onset may also benefit, but this remains unproven. The thrombolytic agents currently in use or being extensively evaluated include streptokinase, urokinase, tissue-type plasminogen activator (t-PA), anisoylated plasminogen streptokinase activator complex (APSAC or anistreplase), and single-chain urokinase-type plasminogen activator (scu-PA). The agent t-PA has the potential advantage of being clot selective and, thereby, relatively fibrinogen sparing, and its efficacy in terms of restoration of vessel patency is less dependent on the time of administration as compared with that of streptokinase and urokinase. It is not yet known whether this will translate into improved patient survival as compared with that achieved by the less-expensive agents streptokinase and APSAC. Treatment regimens of combination thrombolytic agents have been developed, but the optimal combinations have not yet been determined. Patients who are in cardiogenic shock and those in whom thrombolytic therapy is contraindicated can probably benefit from angioplasty or bypass surgery. Results of several studies have suggested that immediate angioplasty after successful thrombolysis is not beneficial; however, the potential benefit of angioplasty or bypass surgery for failed thrombolytic therapy is yet to be evaluated. Although many advances have been made, further research is clearly needed in the area of reperfusion.
多项研究结果充分证实了紧急冠状动脉血运重建对急性心肌梗死（MI）患者的益处。目前，静脉溶栓治疗是许多患者的首选治疗方法，尤其是那些75岁及以下、症状发作后6小时内就诊且无溶栓治疗禁忌证的患者。一些在症状发作后6 - 24小时内接受治疗的患者也可能受益，但这一点尚未得到证实。目前正在使用或正在广泛评估的溶栓药物包括链激酶、尿激酶、组织型纤溶酶原激活剂（t - PA）、茴香酰化纤溶酶原链激酶激活剂复合物（APSAC或茴酰溶栓酶）和单链尿激酶型纤溶酶原激活剂（scu - PA）。t - PA具有血栓选择性的潜在优势，因此相对节省纤维蛋白原，与链激酶和尿激酶相比，其在恢复血管通畅方面的疗效对给药时间的依赖性较小。与价格较低的链激酶和APSAC相比，目前尚不清楚这是否会转化为患者生存率的提高。联合溶栓药物的治疗方案已经制定，但最佳组合尚未确定。心源性休克患者和溶栓治疗禁忌的患者可能从血管成形术或搭桥手术中获益。几项研究结果表明，溶栓成功后立即进行血管成形术并无益处；然而，血管成形术或搭桥手术对溶栓治疗失败患者的潜在益处尚待评估。尽管已经取得了许多进展，但在再灌注领域显然仍需要进一步研究。
