De Luca Giuseppe, Van't Hof Arnoud W J, Gibson C Michael, Cutlip Donald, Zeymer Uwe, Noc Marko, Maioli Mauro, Zorman Simona, Gabriel H Mesquita, Emre Ayse, Rakowski Tomasz, Gyongyosi Maryann, Huber Kurt, Bellandi Francesco, Dudek Dariusz
Division of Cardiology, "Maggiore della Carità" Hospital, Eastern Piedmont University, Novara, Italy.
Division of Cardiology, Hospital "De Weezenlanden", Zwolle, The Netherlands.
Am J Cardiol. 2015 Mar 15;115(6):711-5. doi: 10.1016/j.amjcard.2014.12.030. Epub 2015 Jan 6.
Contrasting data have been so far reported on facilitation with glycoprotein IIb-IIIa inhibitors (GpIIbIIIa) in patients who underwent primary percutaneous coronary intervention. However, it has been demonstrated a time-dependent composition of coronary thrombus in ST-segment elevation myocardial infarction, with more platelets in the first hours. Subsequently, the benefits of early administration of GpIIbIIIa may be affected by the time from symptoms onset to GpIIbIIIa, that therefore is the aim of this study. Our population is represented by 814 patients who underwent GpIIbIIIa facilitated primary angioplasty included in the Early glycoprotein IIb-IIIa inhibitors in primary angioplasty database. Patients were divided according to quartiles of time from symptom onset to GpIIbIIIa administration (≤65 minutes; 65 to 100 minutes; 101 to 178 minutes; and >178 minutes). Myocardial perfusion was evaluated by myocardial blush grade and ST-segment resolution. Time from symptoms onset to GpIIbIIIa was linearly associated with hypertension, diabetes, hypercholesterolemia, and previous myocardial infarction but inversely associated with smoking. Abciximab was more often administrated later from symptoms onset. Time from symptoms onset to GpIIbIIIa was significantly associated with the rate of preprocedural recanalization (thrombolysis in myocardial infarction [TIMI] 2 to 3; p <0.001), postprocedural TIMI 3 flow (p <0.001), the rate of complete ST-segment resolution (p <0.001), and the rate of myocardial blush grade 2 to 3 (p <0.001) and inversely associated with the occurrence of distal embolization (p <0.001). Follow-up data were collected at a median (twenty-fifth to seventy-fifth) of 360 (30 to 1,095) days. A total of 52 patients had died. Time to GpIIbIIIa had a significant impact on mortality (hazard ratio [95% confidence interval] 1.46 [1.11 to 1.92], p = 0.007) that was confirmed after correction for baseline confounding factors (adjusted hazard ratio [95% confidence interval] 1.41 [1.02 to 2.21], p = 0.042). In conclusion, this study showed that in patients who underwent primary angioplasty with upstream GpIIbIIIa, time from symptoms onset to GpIIbIIIa strongly impacts on preprocedural recanalization, distal embolization, myocardial perfusion, and long-term survival.
迄今为止，关于接受直接经皮冠状动脉介入治疗的患者使用糖蛋白IIb-IIIa抑制剂（GpIIbIIIa）的促进作用，已有相互矛盾的数据报道。然而，已证实ST段抬高型心肌梗死患者的冠状动脉血栓成分随时间变化，在最初数小时血小板较多。随后，早期给予GpIIbIIIa的益处可能受症状发作至使用GpIIbIIIa的时间影响，因此本研究以此为目标。我们的研究对象为814例接受GpIIbIIIa辅助直接血管成形术的患者，这些患者纳入了直接血管成形术中早期糖蛋白IIb-IIIa抑制剂数据库。根据症状发作至给予GpIIbIIIa的时间四分位数将患者分组（≤65分钟；65至100分钟；101至178分钟；>178分钟）。通过心肌造影剂增强分级和ST段回落评估心肌灌注。症状发作至GpIIbIIIa的时间与高血压、糖尿病、高胆固醇血症和既往心肌梗死呈线性相关，但与吸烟呈负相关。阿昔单抗更常在症状发作后较晚使用。症状发作至GpIIbIIIa的时间与术前再灌注率（心肌梗死溶栓分级[TIMI]2至3级；p<0.001）、术后TIMI 3级血流（p<0.001）、完全ST段回落率（p<0.001）以及心肌造影剂增强分级2至3级的比例（p<0.001）显著相关，与远端栓塞的发生呈负相关（p<0.001）。随访数据在中位数（第25至第75百分位数）360（30至1095）天收集。共有52例患者死亡。至GpIIbIIIa的时间对死亡率有显著影响（风险比[95%置信区间]1.46[1.11至1.92]，p = 0.007），在对基线混杂因素进行校正后得到证实（校正后风险比[95%置信区间]1.41[1.02至2.21]，p = 0.042）。总之，本研究表明，在接受上游GpIIbIIIa直接血管成形术的患者中，症状发作至GpIIbIIIa的时间对术前再灌注、远端栓塞、心肌灌注和长期生存有强烈影响。
