Inohara Taku, Liang Li, Kosinski Andrzej S, Smith Eric E, Schwamm Lee H, Hernandez Adrian F, Bhatt Deepak L, Fonarow Gregg C, Peterson Eric D, Xian Ying
Duke Clinical Research Institute Duke University Medical Center Durham NC.
Department of Clinical Neurosciences Hotchkiss Brian Institute University of Calgary Canada.
J Am Heart Assoc. 2019 Aug 6;8(15):e012450. doi: 10.1161/JAHA.119.012450. Epub 2019 Jul 20.
Background Intravenous recombinant tissue-type plasminogen activator (rtPA) remains the only medical therapy to improve outcomes for acute ischemic stroke (AIS), but the safety of rtPA in AIS patients with a history of recent myocardial infarction (MI) remains controversial. Methods and Results We sought to determine whether the presence of recent MI would alter the risk of mortality and rtPA-related complications. Multivariate logistic regression models were used to compare in-hospital outcomes between rtPA-treated AIS patients with recent MI within 3 months and those with no history of MI from the Get With The Guidelines-Stroke hospitals between February 2009 and December 2015. Among 40 396 AIS patients aged ≥65 years treated with rtPA, 241 (0.6%) had recent MI, of which 19.5% were ST-segment-elevation myocardial infarction. Patients with recent MI had more severe stroke than those without (median National Institutes of Health Stroke Scale [interquartile range]: 13.0 [7.0-20.0] versus 11.0 [6.0-18.0]). Recent MI was associated with an increased risk of mortality compared with no history of MI (17.4% versus 9.0%; adjusted odds ratio 1.60 [95% CI, 1.10-2.33]; P=0.014), but no statistically significant differences in rtPA-related complications (13.5% versus 9.4%; adjusted odds ratio 1.28 [0.88-1.86]; P=0.19). Recent ST-segment-elevation myocardial infarction was associated with higher risk of death and rtPA-related complications, but non-ST-segment-elevation myocardial infarction was not. Conclusions Among older AIS patients treated with rtPA, recent MI was associated with an increased risk of in-hospital mortality. Further investigations are necessary to determine whether the benefit of rtPA outweighs its risk among AIS patients with recent MI.
背景 静脉注射重组组织型纤溶酶原激活剂（rtPA）仍然是改善急性缺血性卒中（AIS）预后的唯一药物治疗方法，但rtPA在近期有心肌梗死（MI）病史的AIS患者中的安全性仍存在争议。方法与结果 我们试图确定近期发生MI是否会改变死亡率和rtPA相关并发症的风险。采用多变量逻辑回归模型比较2009年2月至2015年12月期间接受rtPA治疗的3个月内发生近期MI的AIS患者与无MI病史的AIS患者在住院期间的预后。在40396例年龄≥65岁接受rtPA治疗的AIS患者中，241例（0.6%）有近期MI，其中19.5%为ST段抬高型心肌梗死。近期发生MI的患者比未发生MI的患者卒中更严重（美国国立卫生研究院卒中量表中位数[四分位间距]：13.0[7.0 - 20.0]对11.0[6.0 - 18.0]）。与无MI病史相比，近期发生MI与死亡风险增加相关（17.4%对9.0%；调整后的优势比1.60[95%CI，1.10 - 2.33]；P = 0.014），但在rtPA相关并发症方面无统计学显著差异（13.5%对9.4%；调整后的优势比1.28[0.88 - 1.86]；P = 0.19）。近期ST段抬高型心肌梗死与死亡和rtPA相关并发症的风险较高相关，但非ST段抬高型心肌梗死则不然。结论 在接受rtPA治疗的老年AIS患者中，近期发生MI与住院死亡率增加相关。有必要进一步研究以确定在近期发生MI的AIS患者中rtPA的获益是否超过其风险。
