Dieker H, Brouwer M A, van Horssen E V, Hersbach F M K J, Aengevaeren W R M, Verheugt F W A, Bär F W H M
Neth Heart J. 2004 Aug;12(7-8):343-346.
The latest meta-analysis comparing fibrinolysis with primary percutaneous intervention (PCI) has fuelled the discussion regarding the best reperfusion therapy for acute ST-elevation myocardial infarction. As far as patients presenting to centres with intervention facilities are concerned, the superiority of primary PCI has been unequivocally demonstrated. However, only a small proportion of patients with St-elevation myocardial infarction primarily present to an intervention centre, the majority go to a hospital without these facilities. The optimal reperfusion strategy for patients presenting to a nonintervention centre or for patients presenting in the prehospital setting has been studied less extensively and the question remains as to whether all these patients should be transferred to an intervention centre to undergo primary PCI. The available data to date on interhospital transport for primary PCI do show a mortality benefit for primary PCI. Yet, as far as inferences to clinical practice are concerned, it remains to be seen whether these studies are truly representative: almost half of patients in the transportation trials received streptokinase, they were treated relatively late, and the subsequent revascularisation strategy was rather conservative. The impact of primary PCI as compared with prehospital fibrinolysis in patients presenting in the prehospital setting has so far only been addressed in the randomised CAPTIM trial, without significant differences in outcome. Additional studies are warranted, with early treatment as primary focus. For patients presenting to non-intervention centres or prehospitally, the impact of triage, and of combined pharmaco-invasive reperfusion strategies are promising fields of further exploration.
最新一项比较纤溶治疗与直接经皮冠状动脉介入治疗（PCI）的荟萃分析引发了关于急性ST段抬高型心肌梗死最佳再灌注治疗的讨论。就就诊于具备介入治疗设施中心的患者而言，直接PCI的优势已得到明确证实。然而，仅有一小部分ST段抬高型心肌梗死患者最初就诊于介入治疗中心，大多数患者前往不具备这些设施的医院。对于就诊于非介入治疗中心的患者或在院前环境中就诊的患者，最佳再灌注策略的研究相对较少，问题仍然是所有这些患者是否都应转至介入治疗中心接受直接PCI。目前关于直接PCI院间转运的现有数据确实显示直接PCI对死亡率有益。然而，就对临床实践的推断而言，这些研究是否真正具有代表性仍有待观察：转运试验中近一半患者接受了链激酶治疗，他们接受治疗的时间相对较晚，随后的血运重建策略相当保守。到目前为止，仅在随机CAPTIM试验中探讨了院前环境中就诊的患者直接PCI与院前纤溶治疗相比的影响，结果无显著差异。有必要开展更多以早期治疗为主要重点的研究。对于就诊于非介入治疗中心或院前的患者，分诊以及联合药物-介入再灌注策略的影响是进一步探索的有前景领域。
