Hatter Cardiovascular Institute, London, United Kingdom; Barts Heart Centre, St Bartholomew's Hospital, London, United Kingdom.
Hatter Cardiovascular Institute, London, United Kingdom; Charité - Universitätsmedizin Berlin, Germany.
Am Heart J. 2019 May;211:60-67. doi: 10.1016/j.ahj.2019.02.005. Epub 2019 Feb 20.
Mineralocorticoid receptor antagonist (MRA) therapy has been shown to prevent adverse left ventricular (LV) remodeling in ST-segment elevation myocardial infarction (STEMI) patients with heart failure. Whether initiating MRA therapy prior to primary percutaneous coronary intervention (PPCI) accrues additional benefit of reducing myocardial infarct size and preventing adverse LV remodeling is not known. We aimed to investigate whether MRA therapy initiated prior to reperfusion reduces myocardial infarct (MI) size and prevents adverse LV remodeling in STEMI patients.
STEMI patients presenting within 12 hours and with a proximal coronary artery occlusion with Thrombolysis In Myocardial Infarction flow grade 0 were consented and randomized to either an intravenous bolus of potassium canrenoate, followed by oral spironolactone for 3 months or matching placebo. The primary endpoint was MI size by cardiovascular magnetic resonance at 3 months.
Sixty-seven patients completed the study. There was no significant difference in the final MI size at 3 months between the 2 groups (placebo: 17 ± 11%, MRA: 16 ± 10%, P = .574). There was also no difference in acute MI size (26 ± 16% versus 23 ± 14%, P = .425) or myocardial salvage (26 ± 12% versus 24 ± 8%, P = .456). At follow-up, there was a trend towards an improvement in LVEF (placebo: 49 ± 8%, MRA: 54 ± 11%, P = .053), and the MRA group had significantly greater percentage decrease in LVEDV (mean difference: -12.2 (95% CI -20.3 to -4.4)%, P = .003) and LVESV (mean difference: -18.2 (95% CI -30.1 to -6.3)%, P = .003).
This pilot study showed no benefit of MRA therapy in reducing MI size in STEMI patients when initiated prior to reperfusion, but there was an improvement in LV remodeling at 3 months. Adequately powered studies are warranted to confirm these findings.
已证实，在心力衰竭的 ST 段抬高型心肌梗死（STEMI）患者中，使用盐皮质激素受体拮抗剂（MRA）治疗可预防不良的左心室（LV）重构。但在直接经皮冠状动脉介入治疗（PPCI）前开始 MRA 治疗是否会额外降低心肌梗死面积并预防不良的 LV 重构尚不清楚。我们旨在研究在 STEMI 患者中，再灌注前开始 MRA 治疗是否会减少心肌梗死（MI）面积并预防不良的 LV 重构。
入选在 12 小时内就诊且前降支近端血管闭塞伴血栓形成溶栓治疗心肌梗死血流分级 0 级的 STEMI 患者，征得其同意后进行随机分组，分别静脉推注坎利酸钾，随后口服螺内酯 3 个月，或给予匹配的安慰剂。主要终点为 3 个月时的心血管磁共振心肌梗死面积。
67 例患者完成了研究。两组在 3 个月时的最终 MI 大小无显著差异（安慰剂组：17±11%，MRA 组：16±10%，P=0.574）。急性 MI 大小（26±16%对 23±14%，P=0.425）或心肌挽救（26±12%对 24±8%，P=0.456）也无差异。随访时，LVEF 有改善趋势（安慰剂组：49±8%，MRA 组：54±11%，P=0.053），MRA 组的 LVEDV（平均差值：-12.2（95%CI-20.3 至-4.4）%，P=0.003）和 LVESV（平均差值：-18.2（95%CI-30.1 至-6.3）%，P=0.003）的降低百分比明显更大。
本研究显示，在 STEMI 患者中，再灌注前开始 MRA 治疗并不能降低 MI 面积，但在 3 个月时 LV 重构得到改善。需要进行充分的、以患者为中心的研究来证实这些发现。
