Assistance Publique-Hôpitaux de Paris, Hôpital Européen Georges Pompidou, Paris, France (N.D., E.P.); INSERM U 970, Paris, France (N.D., E.P.); Université Paris Descartes, Paris, France (N.D., E.P.); Assistance Publique-Hôpitaux de Paris, Hôpital Bichat, Paris, France (P.G.S.); INSERM U 698, Paris, France (P.G.S.); Université Paris Diderot, Paris, France (P.G.S.); Centre Hospitalier Régional Universitaire de Lille, Lille, France (P.G.); Hôpital Jean Minjoz, Besançon, France (F.S.); Université de Franche Comté, Besançon, France (F.S.); Centre Hospitalier d'Annecy, Annecy, France (L.B.); Hôpital du Bocage, Dijon, France (Y.C.); Université de Bourgogne, Dijon, France (Y.C.); Clinique Pasteur, Toulouse, France (J. Fajadet); Centre Hospitalier Régional de Metz-Thionville, Metz, France (K.K.); Hôpital du Haut Levêque, Pessac, France (P.C.); Université Bordeaux Segalen, Bordeaux, France (P.C.); Hôpital Rangueil, Toulouse, France (J. Ferrières); INSERM U1027, Toulouse, France (J. Ferrières); Université Paul Sabatier Toulouse, Toulouse, France (J. Ferrières); Assistance Publique-Hôpitaux de Paris, Hôpital St Antoine, Unité de Recherche Clinique (URCEST), Paris, France (T.S.); INSERM U698, Paris, France (T.S.); and Université Pierre et Marie Curie, Paris, France (T.S.).
Circulation. 2014 Apr 22;129(16):1629-36. doi: 10.1161/CIRCULATIONAHA.113.005874. Epub 2014 Mar 21.
Although primary percutaneous coronary intervention (pPCI) is the preferred reperfusion method for ST-segment-elevation myocardial infarction, it remains difficult to implement in many areas, and fibrinolytic therapy is still widely used.
We assessed 5-year mortality in patients with ST-segment-elevation myocardial infarction from the French Registry of Acute ST-Elevation or Non-ST Elevation Myocardial Infarction (FAST-MI) 2005 according to use and type of reperfusion therapy. Of 1492 patients with ST-segment-elevation myocardial infarction with a first call ≤12 hours from onset, 447 (30%) received fibrinolysis (66% prehospital; 97% with subsequent angiography, 84% with subsequent PCI), 583 (39%) had pPCI, and 462 (31%) received no reperfusion. Crude 5-year survival was 88% for the fibrinolytic-based strategy, 83% for pPCI, and 59% for no reperfusion. Adjusted hazard ratios for 5-year death were 0.73 (95% confidence interval, 0.50-1.06) for fibrinolysis versus pPCI, 0.57 (95% confidence interval, 0.36-0.88) for prehospital fibrinolysis versus pPCI, and 0.63 (95% confidence interval, 0.34-0.91) for fibrinolysis versus pPCI beyond 90 minutes of call in patients having called ≤180 minutes from onset. In propensity score-matched populations, however, survival rates were not significantly different for fibrinolysis and pPCI, both in the whole population (88% lysis, 85% pPCI) and in the population seen early (87% fibrinolysis, 85% pPCI beyond 90 minutes from call).
In a real-world setting, on a nationwide scale, a pharmaco-invasive strategy constitutes a valid alternative to pPCI, with 5-year survival at least equivalent to that of the reference reperfusion method.
www.clinicaltrials.gov. Unique identifier: NCT00673036.
尽管直接经皮冠状动脉介入治疗（pPCI）是治疗 ST 段抬高型心肌梗死（STEMI）的首选再灌注方法，但在许多地区仍难以实施，溶栓治疗仍广泛应用。
我们根据再灌注治疗的使用和类型，评估了来自法国急性 ST 段抬高或非 ST 段抬高心肌梗死注册研究（FAST-MI）2005 年的 STEMI 患者 5 年死亡率。在 1492 例发病 12 小时内首次呼叫的 STEMI 患者中，447 例（30%）接受了溶栓治疗（66%为院前溶栓；97%接受了后续血管造影，84%接受了后续 PCI），583 例（39%）接受了 pPCI，462 例（31%）未接受再灌注治疗。溶栓治疗策略的 5 年生存率为 88%，pPCI 为 83%，未再灌注治疗为 59%。5 年死亡的调整风险比分别为溶栓治疗与 pPCI 相比为 0.73（95%置信区间，0.50-1.06），院前溶栓治疗与 pPCI 相比为 0.57（95%置信区间，0.36-0.88），发病 180 分钟内呼叫时间≤180 分钟的患者中，溶栓治疗与 pPCI 相比为 0.63（95%置信区间，0.34-0.91）。然而，在倾向评分匹配人群中，溶栓治疗和 pPCI 的生存率在整个人群（溶栓治疗 88%，pPCI 85%）和早期人群（溶栓治疗 87%，pPCI 90 分钟后 85%）中均无显著差异。
在真实世界环境中，全国范围内的药物介入策略是一种替代 pPCI 的有效方法，5 年生存率至少与参考再灌注方法相当。
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