Duke Clinical Research Institute, Durham, NC.
University of Colorado, Denver, CO.
Am Heart J. 2014 Jun;167(6):833-9. doi: 10.1016/j.ahj.2014.03.002. Epub 2014 Mar 14.
Timely and appropriate use of antiplatelet and anticoagulant therapies has been shown to improve outcomes among ST-segment elevation myocardial infarction (STEMI) patients but has not been well described in patients transferred for primary percutaneous coronary intervention (PCI).
We examined 16,801 (26%) transfer and 47,329 direct-arrival STEMI patients treated with primary PCI at 441 Acute Coronary Treatment and Intervention Outcomes Network Registry-Get With The Guidelines hospitals. Medication use was compared between transfer and direct-arrival patients to determine if these therapies were delayed or dosed in excess.
Although transfer patients were more likely to receive antiplatelet and anticoagulant therapies before catheterization, they had longer delays to initiation of heparin (35 vs. 25 minutes), clopidogrel (119 vs. 84 minutes), and glycoprotein IIb/IIIa inhibitor (107 vs. 60 minutes, P < .0001 for both). Administration of low-molecular-weight heparin and glycoprotein IIb/IIIa inhibitor at the STEMI-referring hospital was associated with longer delays to reperfusion compared with deferred administration at the STEMI-receiving hospital, whereas early use of unfractionated heparin was not. Among treated patients, those transferred were more likely to receive excess heparin dosing (adjusted odds ratio [OR] 1.28 [95% CI 1.04-1.58] for unfractionated heparin, adjusted OR 1.54 [95% CI 1.09-2.18] for low-molecular-weight heparin) and are associated with higher risks of major bleeding complications (adjusted OR 1.10, 95% CI 1.03-1.17).
ST-segment elevation myocardial infarction patients transferred for primary PCI in community practice are at risk for delayed and excessively dosed antithrombotic therapy, highlighting the need for continued quality improvement to maximize the appropriate use of these important adjunctive therapies.
已证实，ST 段抬高型心肌梗死（STEMI）患者及时、合理使用抗血小板和抗凝治疗可改善其预后，但在接受直接经皮冠状动脉介入治疗（PCI）的患者中，该治疗的应用情况尚未得到充分描述。
我们研究了 441 家急性冠状动脉治疗和干预结果网络-遵循指南注册中心接受直接 PCI 治疗的 16801 例（26%）转院和 47329 例直接到达的 STEMI 患者。比较了转院和直接到达患者的用药情况，以确定这些治疗是否存在延迟或过量使用。
尽管转院患者在接受导管插入术之前更有可能接受抗血小板和抗凝治疗，但他们开始使用肝素（35 分钟对 25 分钟）、氯吡格雷（119 分钟对 84 分钟）和糖蛋白 IIb/IIIa 抑制剂（107 分钟对 60 分钟）的时间延迟更长（均<.0001）。与在 STEMI 接收医院延迟给药相比，在 STEMI 转诊医院给予低分子肝素和糖蛋白 IIb/IIIa 抑制剂与再灌注时间延迟相关，而早期使用未分级肝素则不然。在接受治疗的患者中，转院患者更有可能接受过量的肝素给药（未分级肝素的校正比值比 [OR] 1.28 [95% CI 1.04-1.58]，低分子肝素的校正 OR 1.54 [95% CI 1.09-2.18]），并且与大出血并发症的风险较高相关（校正 OR 1.10，95% CI 1.03-1.17）。
在社区实践中接受直接 PCI 的 STEMI 患者存在抗血栓治疗延迟和过度用药的风险，这突显了持续质量改进的必要性，以最大限度地合理使用这些重要的辅助治疗方法。
