Department of Cardiology, Hospital Santa Cruz, Centro Hospitalar Lisboa Ocidental, Av. Prof. Dr. Reinaldo dos Santos, Carnaxide, 2790-134, Lisbon, Portugal.
CHRC, NOVA Medical School|Faculdade de Ciências Médicas, NMS|FCM, Universidade Nova de Lisboa, Lisbon, Portugal.
Clin Res Cardiol. 2023 Sep;112(9):1322-1330. doi: 10.1007/s00392-023-02235-y. Epub 2023 Jun 19.
Parenteral anticoagulation is recommended for all patients presenting with ST-segment elevation myocardial infarction (STEMI) during primary percutaneous coronary intervention (PPCI). Whether upstream anticoagulation improves clinical outcomes is not well established. We conducted a systematic review and meta-analysis of contemporary evidence on parenteral anticoagulation timing for STEMI patients.
We performed a systematic search of electronic databases (PubMed, CENTRAL, and Scopus) until December 2022. Studies were eligible if they (a) compared upstream anticoagulation with administration at the catheterization laboratory and (b) enrolled patients with STEMI undergoing PPCI. Efficacy outcomes included in-hospital or 30-day mortality, in-hospital cardiogenic shock (CS), and TIMI flow grade pre- and post-PPCI. Safety outcome was defined as in-hospital or 30-day major bleeding.
Overall, seven studies were included (all observational), with a total of 69,403 patients. Upstream anticoagulation was associated with a significant reduction in the incidence of in-hospital or 30-day all-cause mortality (OR 0.61; 95% CI 0.45-0.81; p < 0.001) and in-hospital CS (OR 0.68; 95% CI 0.58-0.81; p < 0.001) and with an increase in spontaneous reperfusion (pre-PPCI TIMI > 0: OR 1.46; 95% CI 1.35-1.57; p < 0.001). Pretreatment was not associated with an increase in major bleeding (OR 1.02; 95% CI 0.70-1.48; p = 0.930).
Upstream anticoagulation was associated with a significantly lower risk of 30-day all-cause mortality, incidence of in-hospital CS, and improved reperfusion of the infarct-related artery (IRA). These findings were not accompanied by an increased risk of major bleeding, suggesting an overall clinical benefit of early anticoagulation in STEMI. These results require confirmation in a dedicated randomized clinical trial.
对于接受直接经皮冠状动脉介入治疗（PPCI）的 ST 段抬高型心肌梗死（STEMI）患者，建议进行静脉内抗凝治疗。目前尚不清楚早期抗凝治疗是否能改善临床结局。我们对当代关于 STEMI 患者静脉内抗凝时机的研究进行了系统回顾和荟萃分析。
我们对电子数据库（PubMed、CENTRAL 和 Scopus）进行了系统检索，检索时间截至 2022 年 12 月。如果研究（a）比较了上游抗凝治疗与导管室给药，以及（b）纳入接受 PPCI 的 STEMI 患者，则符合纳入标准。疗效结局包括住院或 30 天死亡率、住院心源性休克（CS）和 PPCI 前后 TIMI 血流分级。安全性结局定义为住院或 30 天内大出血。
共纳入 7 项研究（均为观察性研究），总计 69403 例患者。与在导管室进行抗凝治疗相比，上游抗凝治疗可显著降低住院或 30 天全因死亡率（OR 0.61；95%CI 0.45-0.81；p<0.001）和住院 CS（OR 0.68；95%CI 0.58-0.81；p<0.001），并增加自发性再灌注（预 PPCI TIMI>0：OR 1.46；95%CI 1.35-1.57；p<0.001）。预处理与大出血发生率增加无关（OR 1.02；95%CI 0.70-1.48；p=0.930）。
上游抗凝治疗与 30 天全因死亡率、住院 CS 发生率降低以及梗死相关动脉（IRA）再灌注改善显著相关。这些发现并未增加大出血的风险，表明在 STEMI 中早期抗凝治疗具有总体临床获益。这些结果需要在专门的随机临床试验中得到证实。
