Viergutz T, Grüttner J, Walter T, Weiss C, Haaff B, Pollach G, Madler C, Luiz T
Klinik für Anästhesiologie und Operative Intensivmedizin, Universitätsmedizin Mannheim, Medizinische Fakultät Mannheim der Universität Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Deutschland.
Zentrale Notaufnahme, Universitätsmedizin Mannheim, Medizinische Fakultät Mannheim der Universität Heidelberg, Mannheim, Deutschland.
Anaesthesist. 2016 Sep;65(9):673-80. doi: 10.1007/s00101-016-0206-z. Epub 2016 Aug 8.
In the current guidelines for the treatment of patients with ST-segment elevation myocardial infarction (STEMI), the European Society of Cardiology (ESC) recommends preclinical fibrinolysis as a reperfusion therapy if, due to long transportation times, no cardiac catheterisation is available within 90-120 min. However, there is little remaining in-depth expertise in this method because fibrinolysis is presently only rarely indicated.
In a rural area in southwestern Germany, where an emergency primary percutaneous coronary intervention was not routinely available within 90-120 min, 156 STEMI patients underwent fibrinolysis with the plasminogen activator reteplase, performed by trained emergency physicians. The practicality of the treatment, as well as complications and the mortality of the patients in the preclinical phase until arrival at the hospital, were retrospectively studied.
The mean time from onset of the symptoms to first medical contact was 114 ± 116 min. The mean interval to the start of fibrinolysis of 13.5 ± 6.4 min was within the 30 min mandated by the ESC. Patients with inferior STEMI represented the largest subgroup. Occurring in 39 cases (25 %), complications due to infarction were relatively common during the prehospital phase, including 15 cases (9.6 %) of cardiogenic shock, but in all cases the complications were manageable. No patient died before arrival at the hospital. As lysis-associated adverse effects, merely two uncomplicated mucosal haemorrhages and one case of mild allergic skin reactions were seen.
In emergency situations with long transportation times to the nearest suitable cardiac catheterisation laboratory, preclinical fibrinolysis in STEMI still represents a workable method. Success of this strategy requires particularly strong training of the emergency physicians in ECG and lysis therapy, and co-operation with nearby cardiac centres.
在目前ST段抬高型心肌梗死（STEMI）患者的治疗指南中，欧洲心脏病学会（ESC）建议，如果由于转运时间过长，在90 - 120分钟内无法进行心脏导管插入术，则将院前溶栓作为一种再灌注治疗方法。然而，由于目前很少使用溶栓疗法，这种方法的深入专业知识所剩无几。
在德国西南部的一个农村地区，在90 - 120分钟内无法常规进行急诊直接经皮冠状动脉介入治疗，156例STEMI患者由训练有素的急诊医生使用纤溶酶原激活剂瑞替普酶进行溶栓治疗。回顾性研究了治疗的实用性、并发症以及患者在院前阶段直至入院的死亡率。
从症状发作到首次医疗接触的平均时间为114 ± 116分钟。溶栓开始的平均间隔时间为13.5 ± 6.4分钟，在ESC规定的30分钟内。下壁STEMI患者是最大的亚组。在39例（25%）患者中，梗死相关并发症在院前阶段相对常见，包括15例（9.6%）心源性休克，但所有病例的并发症均可控制。没有患者在入院前死亡。作为溶栓相关的不良反应，仅观察到两例无并发症的黏膜出血和一例轻度过敏性皮肤反应。
在到最近合适的心脏导管插入实验室的转运时间较长的紧急情况下，STEMI的院前溶栓仍然是一种可行的方法。该策略的成功实施特别需要对急诊医生进行心电图和溶栓治疗方面的强化培训，并与附近的心脏中心合作。
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