Morris J L, Cowan J C
Department of Cardiology, General Infirmary, Leeds, United Kingdom.
Can J Cardiol. 1995 Apr;11 Suppl B:5B-10B.
In addition to well-established roles in the management of stable angina, unstable angina and heart failure, nitrates are widely used in the management of acute infarction and the subacute period of recovery after infarction. A meta-analysis suggested that intravenous nitrate therapy in acute infarction reduced mortality by 35%. Subsequently, two recently reported 'mega' trials, GISSI-3 and ISIS-4, addressed the role of nitrates during and after infarction. The results of the mega trials have failed to substantiate a statistically significant benefit for nitrates. The contrast between the promising results of the meta-analysis and the disappointing results of the mega trials raises a number of issues considered in this paper. The role of nitrates in acute myocardial infarction remains unclear. The mega trials do offer some suggestive evidence of an early benefit of nitrate therapy. If any benefit does exist, it must be much smaller than the 35% reduction in mortality suggested by the meta-analysis. Further trials are required to assess the possibility of an early acute benefit. Any benefits will probably apply only to subgroups of infarcts.
除了在稳定型心绞痛、不稳定型心绞痛和心力衰竭的治疗中发挥既定作用外，硝酸盐还广泛用于急性心肌梗死的治疗以及梗死后亚急性期的恢复治疗。一项荟萃分析表明，急性心肌梗死患者接受静脉硝酸盐治疗可使死亡率降低35%。随后，最近报道的两项“大型”试验——GISSI-3和ISIS-4，探讨了硝酸盐在心肌梗死期间及之后的作用。大型试验的结果未能证实硝酸盐具有统计学上的显著益处。荟萃分析的有前景结果与大型试验的令人失望结果之间的差异引发了本文所讨论的一些问题。硝酸盐在急性心肌梗死中的作用仍不明确。大型试验确实提供了一些提示性证据，表明硝酸盐治疗有早期益处。如果确实存在任何益处，肯定远小于荟萃分析所表明的死亡率降低35%。需要进一步试验来评估早期急性获益的可能性。任何益处可能仅适用于梗死亚组。
