Naylor C D, Armstrong P W
Thrombolysis Guidelines, Ontario Medical Association, Toronto.
CMAJ. 1989 Jun 1;140(11):1289-99.
A consensus group convened under the auspices of the Ontario Medical Association produced guidelines for the use of intravenous thrombolytic agents in acute myocardial infarction. The guidelines, updated to December 1988, include the following points. 1) Any hospital that routinely accepts the responsibility for looking after patients with acute myocardial infarction could offer thrombolytic therapy if monitoring facilities are available and if the staff are experienced in the treatment of cardiac rhythm disturbances. 2) Before treatment, all patients must be carefully screened for factors predisposing to hemorrhagic complications. 3) A physician should be clearly designated as responsible for the care of the patient receiving an infusion and be available in the event of problems. 4) For the two approved agents the usual dosages are as follows: streptokinase, 1.5 million units given over 1 hour; and tissue-type plasminogen activator (tPA), 100 mg over 3 hours, delivered as 60 mg in the first hour (of which 6 to 7 mg should be given as a bolus in the first 1 to 2 minutes) and then an infusion of 20 mg/h over the next 2 hours. 5) Intravenous thrombolytics should be considered for any patient with presumed acute myocardial infarction, as suggested by prolonged chest pain or other appropriate symptoms and typical electrocardiographic changes. Expeditious treatment is critical, since myocardial necrosis occurs within hours. 6) Emergency angiography is indicated for patients with hemodynamic compromise and no apparent response to streptokinase or tPA and in those with recurrent chest pain suggestive of acute myocardial infarction despite an apparent response to intravenous thrombolysis. Angiography before discharge is recommended for patients with postinfarction angina or evidence from noninvasive testing of significant residual ischemic risk. 7) There is insufficient evidence to choose between streptokinase and tPA on the basis of the two most important outcome measures: patient survival and myocardial preservation. More conclusive evidence comparing tPA, streptokinase and another promising agent, acylated plasminogen-streptokinase activator complex, will be available in 1989-90.
一个在安大略省医学协会主持下召集的共识小组制定了急性心肌梗死静脉溶栓药物使用指南。这些更新至1988年12月的指南包括以下要点。1）任何常规承担照顾急性心肌梗死患者责任的医院，若有监测设施且工作人员在治疗心律失常方面经验丰富，均可提供溶栓治疗。2）治疗前，所有患者必须仔细筛查易导致出血并发症的因素。3）应明确指定一名医生负责护理接受输液的患者，并在出现问题时随时待命。4）对于两种获批药物，常用剂量如下：链激酶，150万单位在1小时内给予；组织型纤溶酶原激活剂（tPA），100毫克在3小时内给予，第1小时给予60毫克（其中6至7毫克应在最初1至2分钟内静脉推注），然后在接下来2小时内以20毫克/小时的速度输注。5）对于任何有疑似急性心肌梗死的患者，如出现长时间胸痛或其他适当症状及典型心电图变化，均应考虑静脉溶栓。迅速治疗至关重要，因为心肌坏死在数小时内就会发生。6）对于血流动力学不稳定且对链激酶或tPA无明显反应的患者，以及那些尽管静脉溶栓有明显反应但仍有复发性胸痛提示急性心肌梗死的患者，应进行急诊血管造影。对于梗死后心绞痛患者或无创检查显示有显著残余缺血风险的患者，建议在出院前进行血管造影。7）基于两个最重要的结局指标：患者生存率和心肌保护，在链激酶和tPA之间进行选择的证据不足。比较tPA、链激酶和另一种有前景的药物酰化纤溶酶原 - 链激酶激活剂复合物的更确凿证据将于1989 - 1990年获得。
