梗死面积、休克与心力衰竭：再灌注策略对早期就诊的ST段抬高型心肌梗死患者是否重要？
Infarct Size, Shock, and Heart Failure: Does Reperfusion Strategy Matter in Early Presenting Patients With ST-Segment Elevation Myocardial Infarction?
作者信息
Shavadia Jay, Zheng Yinggan, Dianati Maleki Neda, Huber Kurt, Halvorsen Sigrun, Goldstein Patrick, Gershlick Anthony H, Wilcox Robert, Van de Werf Frans, Armstrong Paul W
机构信息
Canadian VIGOUR Centre, University of Alberta, Edmonton, Alberta, Canada (J.S., Y.Z., N.D.M., P.W.A.).
Department of Cardiology, University of Vienna, Austria (K.H.).
出版信息
J Am Heart Assoc. 2015 Aug 24;4(8):e002049. doi: 10.1161/JAHA.115.002049.
BACKGROUND
A pharmacoinvasive (PI) strategy for early presenting ST-segment elevation myocardial infarction nominally reduced 30-day cardiogenic shock and congestive heart failure compared with primary percutaneous coronary intervention (PPCI). We evaluated whether infarct size (IS) was related to this finding.
METHODS AND RESULTS
Using the peak cardiac biomarker in patients randomized to PI versus PPCI within the Strategic Reperfusion Early After Myocardial Infarction (STREAM) trial, IS was divided into 3 groups: small (≤2 times the upper limit normal [ULN]), medium (>2 to ≤5 times the upper limit normal) and large (>5 times the upper limit normal). The association between IS and 30-day shock and congestive heart failure was subsequently examined. Data on 1701 of 1892 (89.9%) patients randomized to PI (n=853, 50.1%) versus PPCI (n=848, 49.9%) within STREAM were evaluated. A higher proportion of PPCI patients had a large IS (PI versus PPCI: small, 49.8% versus 50.2%; medium, 56.9% versus 43.1%; large, 48.4% versus 51.6%; P=0.035), despite comparable intergroup ischemic times for each reperfusion strategy. As IS increased, a parallel increment in shock and congestive heart failure occurred in both treatment arms, except for the small IS group. The difference in shock and congestive heart failure in the small IS group (4.4% versus 11.6%, P=0.026) in favor of PI likely relates to higher rates of aborted myocardial infarction with the PI strategy (72.7% versus 54.3%, P=0.005). After adjustment, a trend favoring PI persisted in this subgroup (relative risk 0.40, 95% CI 0.15 to 1.06, P=0.064); no difference in treatment-related outcomes was evident in the other 2 groups.
CONCLUSION
A PI strategy appears to alter the pattern of IS after ST-segment elevation myocardial infarction, resulting in more medium and fewer large infarcts compared with PPCI. Despite a comparable number of small infarcts, PI patients in this group had more aborted myocardial infarctions and less 30-day shock and congestive heart failure.
CLINICAL TRIAL REGISTRATION
URL: http://ClinicalTrials.gov. Unique identifier: NCT00623623.
背景
对于早期表现为ST段抬高型心肌梗死的患者，与直接经皮冠状动脉介入治疗（PPCI）相比，药物介入（PI）策略名义上可降低30天的心源性休克和充血性心力衰竭发生率。我们评估了梗死面积（IS）是否与这一结果相关。
方法与结果
在心肌梗死后早期战略再灌注（STREAM）试验中，利用随机分组至PI组与PPCI组患者的心肌生物标志物峰值，将梗死面积分为3组：小（≤正常上限[ULN]的2倍）、中（>正常上限的2倍至≤5倍）和大（>正常上限的5倍）。随后研究梗死面积与30天休克和充血性心力衰竭之间的关联。对STREAM试验中随机分组至PI组（n = 853，50.1%）与PPCI组（n = 848，49.9%）的1892例患者中的1701例（89.9%）的数据进行了评估。尽管每种再灌注策略的组间缺血时间相当，但PPCI组中梗死面积大的患者比例更高（PI组与PPCI组：小梗死面积，49.8%对50.2%；中等梗死面积，56.9%对43.1%；大梗死面积，48.4%对51.6%；P = 0.035）。随着梗死面积增加，除小梗死面积组外，两个治疗组的休克和充血性心力衰竭均呈平行增加。小梗死面积组中休克和充血性心力衰竭的差异（4.4%对11.6%，P = 0.026）有利于PI组，这可能与PI策略下心肌梗死未成功的发生率较高有关（72.7%对54.3%，P = 0.005）。调整后，该亚组中有利于PI组的趋势仍然存在（相对风险0.40，95%CI 0.15至1.06，P = 0.064）；其他两组在治疗相关结局方面无明显差异。
结论
PI策略似乎改变了ST段抬高型心肌梗死后的梗死面积模式，与PPCI相比，导致中等梗死面积更多，大梗死面积更少。尽管小梗死面积的数量相当，但该组中PI组患者心肌梗死未成功的情况更多，30天休克和充血性心力衰竭更少。
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