Schreiber T L, Macina G, McNulty A, Bunnell P, Kikel M, Miller D H, Devereux R B, Tenney R, Cowley M, Zola B
Division of Cardiology, William Beaumont Hospital, Royal Oak, Michigan.
Am J Cardiol. 1989 Oct 15;64(14):840-4. doi: 10.1016/0002-9149(89)90828-x.
The pivotal role of thrombosis in unstable angina and non-Q-wave myocardial infarction has been established recently. To assess the value and safety of thrombolytic therapy compared to conventional antithrombotic therapy (aspirin) in arresting progression in this setting to recurrent ischemic end-points, 25 patients presenting with unstable angina and an electrocardiogram showing subendocardial ischemia were randomized to receive either aspirin 325 mg daily, or urokinase 3 x 10(6) U intravenously, over 30 minutes followed by heparin. Incidence of endpoints (intractable ischemia requiring mechanical intervention, new myocardial infarction or death) was determined over 7 days. Coronary arteriography was performed at 24 to 72 hours to determine extent of coronary artery disease and morphologic severity of the culprit lesion, graded by a semiquantitative scoring system ranging from 4+ (definite thrombosis) to 0 (chronic lesion). In the first 24 hours, 7 of 13 aspirin versus 1 of 12 urokinase patients exhibited ischemia progression (p less than 0.05). By 7 days, progression to a primary ischemic endpoint occurred in 8 of 13 aspirin patients (3 myocardial infarctions and 5 intractable ischemias) versus 3 of 12 urokinase patients (2 intractable ischemias and 1 death) (p = 0.18). The apparent benefit of urokinase followed by heparin compared to conventional aspirin therapy in arresting early progression of unstable angina or non-Q-wave myocardial infarction was not associated with enhanced culprit lesion morphology (mean lesion severity score 2.7 +/- 1.5 vs 2.8 +/- 1.6 in aspirin-treated patients). Large scale, randomized trials to assess the clinical utility of urokinase for unstable angina are warranted.
血栓形成在不稳定型心绞痛和非Q波心肌梗死中的关键作用最近已得到证实。为了评估与传统抗血栓治疗（阿司匹林）相比，溶栓治疗在阻止这种情况下进展为复发性缺血终点方面的价值和安全性，将25例表现为不稳定型心绞痛且心电图显示心内膜下缺血的患者随机分为两组，一组每天服用325毫克阿司匹林，另一组静脉注射3×10⁶单位尿激酶，持续30分钟，随后使用肝素。在7天内确定终点事件（需要机械干预的顽固性缺血、新发心肌梗死或死亡）的发生率。在24至72小时进行冠状动脉造影，以确定冠状动脉疾病的程度和罪犯病变的形态学严重程度，通过从4+（明确血栓形成）到0（慢性病变）的半定量评分系统进行分级。在最初的24小时内，13例服用阿司匹林的患者中有7例出现缺血进展，而12例使用尿激酶的患者中有1例出现缺血进展（p<0.05）。到第7天，13例服用阿司匹林的患者中有8例进展为主要缺血终点（3例心肌梗死和5例顽固性缺血），而12例使用尿激酶的患者中有3例（2例顽固性缺血和1例死亡）（p = 0.18）。与传统阿司匹林治疗相比，尿激酶加肝素在阻止不稳定型心绞痛或非Q波心肌梗死早期进展方面的明显益处与罪犯病变形态学改善无关（阿司匹林治疗患者的平均病变严重程度评分为2.7±1.5，而尿激酶治疗患者为2.8±1.6）。有必要进行大规模随机试验以评估尿激酶对不稳定型心绞痛的临床效用。
