Jugdutt B I, Warnica J W
Department of Medicine, University of Alberta, Edmonton, Canada.
Circulation. 1988 Oct;78(4):906-19. doi: 10.1161/01.cir.78.4.906.
To determine 1) whether the effect of intravenous nitroglycerin (NG) therapy during acute myocardial infarction on creatine kinase infarct size is influenced by infarct location (anterior vs. inferior), timing (therapy less than 4 hours vs. greater than or equal to 4 hours after onset of pain), and dose response (mean blood pressure greater than or equal to 80 mm Hg vs. less than 80 mm Hg during the first 12 hours) and 2) whether NG therapy modifies infarct expansion, 310 patients were randomly allocated to NG (n = 154) and control (n = 156) groups. NG infusion was titrated to lower mean blood pressure by 10% in normotensive and 30% in hypertensive patients, but not below 80 mm Hg, and was maintained for 39 hours. Measurements included clinical variables, creatine kinase infarct size (geq) as well as left ventricular (LV) asynergy, LV ejection fraction, expansion index, and thinning ratio on serial two-dimensional echocardiography. Compared with controls, creatine kinase infarct size was less in the NG group (41 vs. 55 geq, p less than 0.001), in anterior (44 vs. 58 geq, p less than 0.05), and inferior (39 vs. 53 geq, p less than 0.025) NG subgroups, and in early than late NG subgroups (43% vs. 22% decrease). Other indexes of infarct size also improved (p less than or equal to 0.05) with NG compared with controls. Thus, by 10 days, LV asynergy was 40% less, LV ejection fraction was 22% more, and Killip class score was 41% less. A negative effect of mean blood pressure less than 80 mm Hg with NG was reflected in these indexes. In addition, expansion index increased (p less than 0.001) by 31% and thinning ratio decreased (p less than 0.001) by 17% in controls by 10 days but remained unchanged with NG. Infarct-related major complications were less frequent in the NG than the control groups: infarct expansion syndrome (2% vs. 15%, p less than 0.0005), LV thrombus (5% vs. 22%, p less than 0.0005), cardiogenic shock (5% vs. 15%, p less than 0.005), and infarct extension (11% vs. 22%, p less than 0.025). Mortality was less in NG than in control groups in-hospital (14% vs. 26%, p less than 0.01), at 3 months (16% vs. 28%, p less than 0.025) and 12 months (21% vs. 31%, p less than 0.05), but this advantage was only found in the anterior subgroups.(ABSTRACT TRUNCATED AT 250 WORDS)
1）急性心肌梗死期间静脉输注硝酸甘油（NG）治疗对肌酸激酶梗死面积的影响是否受梗死部位（前壁与下壁）、时间（疼痛发作后治疗时间小于4小时与大于或等于4小时）和剂量反应（最初12小时内平均血压大于或等于80 mmHg与小于80 mmHg）的影响；2）NG治疗是否会改变梗死扩展，将310例患者随机分为NG组（n = 154）和对照组（n = 156）。在血压正常的患者中，NG输注滴定至使平均血压降低10%，高血压患者降低30%，但不低于80 mmHg，并维持39小时。测量指标包括临床变量、肌酸激酶梗死面积（geq）以及连续二维超声心动图上的左心室（LV）运动不协调、左心室射血分数、扩展指数和变薄率。与对照组相比，NG组的肌酸激酶梗死面积较小（41 vs. 55 geq，p < 0.001），在前壁（44 vs. 58 geq，p < 0.05）和下壁（39 vs. 53 geq，p < 0.025）的NG亚组中也较小，且早期NG亚组比晚期亚组小（降低43% vs. 22%）。与对照组相比，NG治疗后其他梗死面积指标也有所改善（p ≤ 0.05）。因此，到第10天时，LV运动不协调减少40%，左心室射血分数增加22%，Killip分级评分降低41%。这些指标反映了NG治疗时平均血压低于80 mmHg的负面影响。此外，对照组到第10天时扩展指数增加（p < 0.001）31%，变薄率降低（p < 0.001）17%，而NG组保持不变。NG组梗死相关的主要并发症比对照组少：梗死扩展综合征（2% vs. 15%，p < 0.0005）、LV血栓形成（5% vs. 22%）、心源性休克（5% vs. 15%，p < 0.005）和梗死延展（11% vs. 22%，p < 0.025）。NG组住院期间（14% vs. 26%，p < 0.01）、3个月时（16% vs. 28%，p < 0.025）和12个月时（21% vs. 31%，p < 0.05）的死亡率低于对照组，但这种优势仅在前壁亚组中发现。（摘要截断于250字）
