Inserm U961, cardiology, centre d'investigations cliniques CIC9501, institut Lorrain du cœur et des vaisseaux, CHU de Nancy, 2, avenue du Morvan, 54500 Vandoeuvre-Lès-Nancy, France.
University of Alabama at Birmingham and VA medical center, Birmingham, AL, USA.
Arch Cardiovasc Dis. 2014 Mar;107(3):149-57. doi: 10.1016/j.acvd.2014.01.010. Epub 2014 Mar 11.
Differential outcomes in patients with acute systolic heart failure (HF) complicating acute myocardial infarction (AMI) and the efficacy of mineralocorticoid receptor antagonists according to non-ST-segment and ST-segment elevation myocardial infarction (NSTEMI, STEMI) status has not been specifically investigated.
In the EPHESUS study, 6632 patients with acute HF and left ventricular ejection fraction<40% were randomized 3-14 days post-AMI (median 7.3 ± 3.0 days) to receive eplerenone (n=3319) or placebo (n=3313). Among them, 6392 patients with available data on baseline ST-segment status (4634 STEMI; 1758 NSTEMI) were compared using a Cox model analysis stratified according to quintiles of propensity score (PS), taking into account major baseline risk factors, including revascularization.
STEMI and NSTEMI patients differed significantly across a large variety of baseline characteristics. During 30 months of follow-up, all-cause death occurred in 19% and 13% (P<0.0001), cardiovascular death in 16% and 12% (P<0.0001), cardiovascular death and hospitalization in 33% and 26% (P<0.0001) and death from progression of HF in 5% and 3% (P<0.0001) of unadjusted NSTEMI and STEMI patients, respectively. After Cox model PS adjustment without revascularization, NSTEMI status still proved to be a risk factor for all-cause death, cardiovascular death and death from progression of HF. After Cox model PS adjustment including revascularization, none of the outcomes differed between STEMI and NSTEMI patients. Eplerenone morbidity and mortality benefits were consistent in the STEMI and NSTEMI subgroups.
In patients with acute systolic HF complicating AMI, eplerenone improves outcomes equally in STEMI and NSTEMI patients. Worse outcomes associated with NSTEMI could be explained by more co-morbidities, less aggressive therapies and, mainly, less frequent revascularization.
急性收缩性心力衰竭（HF）合并急性心肌梗死（AMI）患者的预后不同，以及根据非 ST 段抬高心肌梗死（NSTEMI）和 ST 段抬高心肌梗死（STEMI）状态使用盐皮质激素受体拮抗剂的疗效尚未得到专门研究。
在 EPHESUS 研究中，6632 例急性 HF 和左心室射血分数<40%的患者在 AMI 后 3-14 天（中位数 7.3±3.0 天）随机分为依普利酮组（n=3319）或安慰剂组（n=3313）。其中，6392 例基线 ST 段状态有可用数据的患者（4634 例 STEMI；1758 例 NSTEMI），使用 Cox 模型分析，根据倾向评分（PS）的五分位数分层，考虑了包括血运重建在内的主要基线风险因素。
STEMI 和 NSTEMI 患者在各种基线特征方面存在显著差异。在 30 个月的随访期间，全因死亡分别为 19%和 13%（P<0.0001），心血管死亡分别为 16%和 12%（P<0.0001），心血管死亡和住院分别为 33%和 26%（P<0.0001），HF 进展导致的死亡分别为 5%和 3%（P<0.0001）。未进行血运重建的 Cox 模型 PS 调整后，NSTEMI 状态仍为全因死亡、心血管死亡和 HF 进展导致的死亡的危险因素。进行血运重建的 Cox 模型 PS 调整后，STEMI 和 NSTEMI 患者的预后无差异。依普利酮对 STEMI 和 NSTEMI 亚组的发病率和死亡率均有获益。
在急性收缩性 HF 合并 AMI 的患者中，依普利酮在 STEMI 和 NSTEMI 患者中的结局改善效果一致。与 NSTEMI 相关的更差的预后可能是由更多的合并症、较少的积极治疗以及主要是较少的血运重建引起的。
