Macherey-Meyer Sascha, Heyne Sebastian, Meertens Max Maria, Finke Karl, Mauri Victor, Ahrens Ingo, Baer Frank Michael, Eberhardt Frank, Horlitz Marc, Sinning Jan-Malte, Meissner Axel, Rosswinkel Benjamin, Baldus Stephan, Adler Christoph, Lee Samuel
University of Cologne, Faculty of Medicine and University Hospital Cologne, Clinic III for Internal Medicine; Cardiology III - Angiology, Department of Cardiology, University Hospital of Johannes Gutenberg University, Mainz; Department of Emergency Medicine, Leverkusen Hospital, Leverkusen; Department of Cardiology and Internal Intensive Care Medicine, Augustinian Hospital, Academic Teaching Hospital, Cologne; Department of Medicine and Cardio-Diabetes Center Cologne, St. Antonius Hospital, Cologne; Department of Cardiology and Internal Intensive Care Medicine, Cologne-Kalk Protestant Hospital, Cologne; Department of Cardiology, Electrophysiology, and Rhythmology, Porz on Rhine Hospital, Cologne; Department of Internal Medicine III - Cardiology, St. Vincent Hospital, Cologne; Department of Medicine II, Merheim Hospital, Cologne Municipal Hospital Group, Cologne; Institute for Medical Statistics and Bioinformatics, Faculty of Medicine and University Hospital, University of Cologne.
Dtsch Arztebl Int. 2024 Dec 13;121(25):833-839. doi: 10.3238/arztebl.m2024.0212.
Patients with ST-segment elevation myocardial infarction (STEMI) are often pretreated with unfractionated heparin (UFH) before a primary percutaneous coronary intervention (PPCI). UFH pretreatment is intended to lessen the thrombotic burden, but there have been conflicting study findings on its safety and efficacy. We assessed the risks and benefits of UFH pretreatment with a retrospective analysis of registry data from the STEMI network of a German metropolitan region.
Data from patients with STEMI referred for PPCI from 2005 to 2020 were evaluated with an adjusted outcome analysis, including propensity score matching (PSM). The endpoints included the patency of the infarct-related artery (IRA) after PPCI, in-hospital mortality, access-site bleeding, and the peak creatine kinase (CK) level.
We assessed data from 4632 patients with STEMI: 4420 (95.4%) were pretreated with UFH, and 212 (4.6%) were not. After PSM of 511 vs. 187 patients, the adjusted odds ratios for the various endpoints were (pretreatment vs. no pretreatment, with 95% confidence intervals): for impaired flow of the IRA, 1.01 [0.59; 1.74]; for in-hospital mortality, 1.46 [0.88; 2.42]; and for access-site bleeding, 0.59 [0.14; 2.46]. The peak creatine kinase levels were similar in the two groups (median, 1248.0 vs. 1376.5 U/L, estimated difference -134 [-611; 341]).
UFH pretreatment was less frequently performed in STEMI patients who had undergone cardiopulmonary resuscitation. UFH pretreatment was not associated with increased access-site bleeding, nor was it found to have significantly higher efficacy with respect to the relevant endpoints. The risks and benefits of UFH pretreatment should be weighed individually in each case, as evidence from high-quality clinical trials is lacking. Data from the existing literature suggest that no pretreatment is an option to be considered, as are certain alternative antithrombotic strategies.
ST段抬高型心肌梗死（STEMI）患者在进行直接经皮冠状动脉介入治疗（PPCI）前常接受普通肝素（UFH）预处理。UFH预处理旨在减轻血栓负荷，但关于其安全性和有效性的研究结果存在矛盾。我们通过对德国一个大都市地区STEMI网络登记数据的回顾性分析，评估了UFH预处理的风险和益处。
对2005年至2020年因PPCI转诊的STEMI患者的数据进行调整后的结局分析，包括倾向评分匹配（PSM）。终点包括PPCI后梗死相关动脉（IRA）的通畅情况、住院死亡率、穿刺部位出血以及肌酸激酶（CK）峰值水平。
我们评估了4632例STEMI患者的数据：4420例（95.4%）接受了UFH预处理，212例（4.6%）未接受。在对511例与187例患者进行PSM后，各终点的调整优势比为（预处理组与未预处理组，95%置信区间）：IRA血流受损方面，1.01[0.59；1.74]；住院死亡率方面，1.46[0.88；2.42]；穿刺部位出血方面，0.59[0.14；2.46]。两组的肌酸激酶峰值水平相似（中位数分别为1248.0和1376.5 U/L，估计差异为-134[-611；341]）。
接受过心肺复苏的STEMI患者较少进行UFH预处理。UFH预处理与穿刺部位出血增加无关，在相关终点方面也未发现其有效性显著更高。由于缺乏高质量临床试验的证据，应在每种情况下单独权衡UFH预处理的风险和益处。现有文献数据表明，不进行预处理是一种可考虑的选择，某些替代抗栓策略也是如此。
