ST 段抬高型心肌梗死患者症状发作 12 小时后行直接经皮冠状动脉介入治疗再灌注可获益。
Benefit From Reperfusion With Primary Percutaneous Coronary Intervention Beyond 12 Hours of Symptom Duration in Patients With ST-Segment-Elevation Myocardial Infarction.
机构信息
Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Denmark (L.N.-C., J.L., D.E.H., K.A.A., L.E.B., S.H., K.K., L.K., N.V., L.H., T.E.).
Department of Cardiology, Zealand University Hospital, Roskilde, Denmark (H.K.).
出版信息
Circ Cardiovasc Interv. 2018 Sep;11(9):e006842. doi: 10.1161/CIRCINTERVENTIONS.118.006842.
BACKGROUND
Guidelines recommend primary percutaneous coronary intervention (PCI) in patients with ST-segment-elevation myocardial infarction (STEMI) presenting ≥12 hours of symptom onset in the presence of ongoing ischemia. However, data supporting this recommendation are limited. We evaluated the effect of primary PCI on reperfusion success, using cardiac magnetic resonance, in STEMI patients with signs of ongoing ischemia presenting 12 to 72 hours after symptom onset compared with STEMI patients presenting <12 hours.
METHODS AND RESULTS
We included 865 STEMI patients who underwent cardiac magnetic resonance just after index PCI and 3 months later. Despite equal area at risk (34±12% versus 33±12%; P=0.370), patients presenting late (n=58) had larger final infarct size (13% [interquartile range, 9-24] versus 11% [interquartile range, 4-19]; P=0.037) and smaller myocardial salvage index (0.58 [interquartile range, 0.39-0.71] versus 0.65 [interquartile range, 0.49-0.84]; P=0.021) compared with patients presenting <12 hours after symptom onset (n=807). However, 65% of late-presenting patients achieved substantial myocardial salvage ≥0.50, and area under the curve for symptom onset to PCI as predictor of a myocardial salvage index ≥0.50 was poor (0.58 [95% CI, 0.53-0.63]; P<0.001). In addition, final infarct size, salvage index and left ventricular function correlated weakly with duration from symptom onset to primary PCI ( R values <0.05).
CONCLUSIONS
STEMI patients with signs of ongoing ischemia treated with primary PCI 12 to 72 hours after symptom onset had less myocardial salvage and developed larger infarcts. However, a large proportion achieved substantial myocardial salvage indicating a benefit from primary PCI in late-presenting patients.
CLINICAL TRIAL REGISTRATION
URL: https://www.clinicaltrials.gov . Unique identifiers: NCT01435408 and NCT01960933.
背景
指南建议在出现持续缺血症状的 ST 段抬高型心肌梗死（STEMI）患者中，在症状发作 12 小时以上时进行直接经皮冠状动脉介入治疗（PCI）。然而，支持这一建议的数据有限。我们使用心脏磁共振评估了在症状发作 12 至 72 小时后出现持续缺血迹象的 STEMI 患者与症状发作 12 小时内的 STEMI 患者相比，直接 PCI 对再灌注成功的影响。
方法和结果
我们纳入了 865 名在指数 PCI 后立即进行心脏磁共振检查并在 3 个月后再次进行检查的 STEMI 患者。尽管危险区面积相等（34±12% 与 33±12%；P=0.370），但晚发患者（n=58）的最终梗死面积更大（13%[四分位间距，9-24] 与 11%[四分位间距，4-19]；P=0.037），心肌挽救指数更小（0.58[四分位间距，0.39-0.71] 与 0.65[四分位间距，0.49-0.84]；P=0.021）。然而，65%的晚发患者的心肌挽救指数≥0.50，症状发作至 PCI 的曲线下面积作为心肌挽救指数≥0.50 的预测因子较差（0.58[95%CI，0.53-0.63]；P<0.001）。此外，最终梗死面积、挽救指数和左心室功能与从症状发作至直接 PCI 的时间相关性较弱（R 值<0.05）。
结论
症状发作 12 至 72 小时后接受直接 PCI 治疗的出现持续缺血症状的 STEMI 患者的心肌挽救较少，梗死面积较大。然而，很大一部分患者的心肌挽救程度较大，表明直接 PCI 对晚发患者有益。
临床试验注册
网址：https://www.clinicaltrials.gov。唯一标识符：NCT01435408 和 NCT01960933。
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