梗死前心绞痛作为急性心肌梗死患者冠状动脉溶栓更迅速的预测指标。

Preinfarction angina as a predictor of more rapid coronary thrombolysis in patients with acute myocardial infarction.

作者信息

Andreotti F, Pasceri V, Hackett D R, Davies G J, Haider A W, Maseri A

机构信息

Institute of Cardiology, Catholic University, Rome, Italy.

出版信息

N Engl J Med. 1996 Jan 4;334(1):7-12. doi: 10.1056/NEJM199601043340102.

DOI:10.1056/NEJM199601043340102

PMID:7494588

Abstract

BACKGROUND

When a myocardial infarction is preceded by angina, the infarct tends to be smaller than when there is no preinfarction angina. Prompt recanalization of the occluded infarct-related artery is crucial in limiting the size of the infarct. We prospectively studied the relation among preinfarction unstable angina, the speed of coronary reperfusion, and the size of the infarct in patients with acute myocardial infarction receiving thrombolytic therapy.

METHODS

We compared 14 patients who had unstable angina during the week before myocardial infarction with 9 patients who had no preinfarction angina. Coronary arteriograms were obtained at base line and 15, 35, 55, and 90 minutes and 24 hours after the start of thrombolytic therapy. The size of the infarct was estimated on the basis of creatine kinase and creatine kinase MB levels, which were measured every 4 hours during the first 24 hours.

RESULTS

Complete reperfusion (a flow of grade 3 according to the Thrombolysis in Myocardial Infarction classification) was achieved at 35 minutes in 64 percent of the patients with preinfarction angina but in none of those without preinfarction angina (P = 0.006); at 55 minutes in 86 percent and 38 percent, respectively (P = 0.05); and at 90 minutes in 86 percent and 50 percent, respectively (P = 0.14). The mean (+/- SD) time to reperfusion was 27 +/- 16 minutes in the group with preinfarction angina and 48 +/- 17 minutes in the group without preinfarction angina (P = 0.04); the peak creatine kinase levels were 1118 +/- 783 and 2395 +/- 1615 U per liter, respectively (P = 0.03); the peak creatine kinase MB levels were 102 +/- 67 and 251 +/- 186 U per liter, respectively (P = 0.009); and the 24-hour integrated creatine kinase MB levels were 1716 +/- 1171 and 4267 +/- 3252 U.liter-1 x 24 hours, respectively (P = 0.009). The time to reperfusion was positively correlated with the indexes of infarct size (r > or = 0.53, P < or = 0.02).

CONCLUSIONS

In patients with acute myocardial infarction preceded by unstable angina, as compared with those without preinfarction angina, thrombolytic therapy resulted in more rapid reperfusion and smaller infarcts. Earlier myocardial reperfusion may thus account for the smaller infarct size in patients with preinfarction angina.

摘要

背景

当心肌梗死发生前有胸痛症状时，梗死范围往往比无梗死前胸痛症状时要小。迅速开通梗死相关动脉对于限制梗死范围至关重要。我们前瞻性地研究了梗死前不稳定型心绞痛、冠状动脉再灌注速度与接受溶栓治疗的急性心肌梗死患者梗死范围之间的关系。

方法

我们将14例心肌梗死前一周内有不稳定型心绞痛的患者与9例无梗死前心绞痛的患者进行了比较。在溶栓治疗开始时、15、35、55和90分钟以及24小时时进行冠状动脉造影。根据肌酸激酶和肌酸激酶MB水平估计梗死范围，在最初24小时内每4小时测量一次。

结果

梗死前心绞痛患者中64%在35分钟时实现了完全再灌注（根据心肌梗死溶栓分类为3级血流），而无梗死前心绞痛的患者中无一例实现（P = 0.006）；55分钟时分别为86%和38%（P = 0.05）；90分钟时分别为86%和50%（P = 0.14）。梗死前心绞痛组再灌注的平均（±标准差）时间为27±16分钟，无梗死前心绞痛组为48±17分钟（P = 0.04）；肌酸激酶峰值水平分别为1118±783和2395±1615 U/L（P = 0.03）；肌酸激酶MB峰值水平分别为102±67和251±186 U/L（P = 0.009）；24小时肌酸激酶MB积分水平分别为1716±1171和4267±3252 U·L-1×24小时（P = 0.009）。再灌注时间与梗死范围指标呈正相关（r≥0.53，P≤0.02）。