Cassidy D B, Smalling R W
Division of Cardiology, University of Texas Health Science Center, Houston.
Crit Care Clin. 1989 Jul;5(3):435-53.
Several issues confront the physician treating the patient with an acute infarction. If the patient is a thrombolytic candidate, a 20 to 30 per cent failure rate still exists, and it is difficult to predict on clinical grounds who has had a successful trial of thrombolytics or not; therefore, considerable clinical judgment must be applied. If the patient has relief of pain and diminished ST segment elevation, it is likely that thrombolytic therapy has been successful. Limitations concerning the benefits of thrombolytic or angioplasty therapy for the acute infarction also exist with regard to baseline patient characteristics. Older patients, especially women, seem to have more complications and less beneficial results from acute revascularization than do others. Patients with anterior infarctions as compared with posterior or inferior wall infarctions probably have a higher benefit from intracoronary thrombolysis. The acute myocardial infarction patient can be treated in multiple ways. Based on the preceding information and our own clinical experience, some recommendations can be made. Other sources with their own recommendations are available as well. First, because of the uncertainty still present in deciding optimum therapy for any given patient, as many patients as possible should be included in randomized prospective clinical trials that are now ongoing. If the patient or treating physician elects not to take part in such a trial, much of the therapy will be based on available resources. In small hospitals without acute catheterization or angioplasty facilities, intravenous thrombolytic therapy should be instituted as quickly as possible. In patients who are not able to receive thrombolytic therapy, acute catheterization with consideration for either angioplasty or acute bypass surgery should be undertaken if the patients are relatively young and early on in their course. Treatment of older patients, especially women, should be tempered by the knowledge that there are diminishing returns in aggressive approaches to these patients. It would appear that the presence of cardiogenic shock itself, although a predictor of higher cardiac mortality, should not preclude an aggressive approach and indeed this patient may benefit greatly from revascularization as well as pharmacologic and mechanical support of the cardiovascular system. If thrombolytic therapy without catheterization is undertaken, there remains the potential for either nonrevascularization or early closure.(ABSTRACT TRUNCATED AT 400 WORDS)
治疗急性梗死患者时，医生面临几个问题。如果患者适合进行溶栓治疗，仍有20%至30%的失败率，且很难根据临床情况预测谁的溶栓试验成功与否；因此，必须运用相当多的临床判断力。如果患者疼痛缓解且ST段抬高减轻，则溶栓治疗可能成功。关于溶栓或血管成形术治疗急性梗死的益处，在患者基线特征方面也存在局限性。老年患者，尤其是女性，似乎比其他患者有更多并发症，急性血运重建带来的益处也更少。与后壁或下壁梗死相比，前壁梗死患者可能从冠状动脉内溶栓中获益更高。急性心肌梗死患者可以有多种治疗方式。根据上述信息及我们自己的临床经验，可以提出一些建议。也有其他来源给出了他们自己的建议。首先，由于在为任何特定患者确定最佳治疗方案时仍存在不确定性，应将尽可能多的患者纳入正在进行的随机前瞻性临床试验。如果患者或治疗医生选择不参加此类试验，大部分治疗将基于可用资源。在没有急性导管插入术或血管成形术设施的小医院，应尽快开始静脉溶栓治疗。对于无法接受溶栓治疗的患者，如果相对年轻且病程早期，应考虑进行急性导管插入术，并考虑是否进行血管成形术或急性搭桥手术。对于老年患者，尤其是女性，治疗时应考虑到对这些患者采取积极治疗的收益递减。心源性休克本身虽然是心脏死亡率较高的一个预测因素，但似乎不应排除采取积极治疗方法，实际上这类患者可能从血运重建以及心血管系统的药物和机械支持中获益巨大。如果在未进行导管插入术的情况下进行溶栓治疗，仍有可能出现未实现血运重建或早期血管闭塞的情况。（摘要截选至400字）
