Hohnloser S H, Franck P, Klingenheben T, Zabel M, Just H
University Hospital, Department of Cardiology, Freiburg, Germany.
Circulation. 1994 Oct;90(4):1747-56. doi: 10.1161/01.cir.90.4.1747.
Successful reperfusion of the infarct-related artery in patients with acute myocardial infarction has been shown to reduce in-hospital as well as 1-year mortality. Besides the thrombolysis-induced myocardial salvage, there is increasing evidence that an open infarct-related artery results in increased electrical stability of the heart and that this effect is at least in part responsible for the favorable long-term outcome of these patients. The exact incidence of arrhythmic events during the first year after myocardial infarction and the predictive value of different risk factors for these complications, however, have not been determined in patients in the thrombolytic era.
A total of 173 patients with acute myocardial infarction, 51% treated with thrombolysis, were prospectively entered into the study. At the time of hospital discharge, signal-averaged ECG, Holter monitoring, radionuclide angiography, coronary angiography, and levocardiography were performed in all patients. An open infarct-related artery was documented in 136 patients. The overall incidence of late potentials was 24% (41 patients). By multivariate analysis, an occluded infarct-related artery (P = .04) and the presence of regional wall motion abnormalities (P = .02) were the strongest independent predictors for the development of a late potential. Residual ischemia was treated by either percutaneous transluminal coronary angioplasty or surgery in 86 of 173 patients (50%). Seventy percent of the patients received beta-blocker therapy. During a mean follow-up of 12 +/- 5 months, 7 patients died suddenly or had ventricular fibrillation documented, while only 2 developed sustained monomorphic ventricular tachycardia. Overall 1-year mortality was 4.1%. Multivariate analysis revealed only an occluded infarct-related artery as an independent predictor of arrhythmic complications (P = .017).
In patients with acute myocardial infarction treated according to contemporary therapeutic guidelines, with a large proportion of individuals undergoing coronary artery revascularization, a low incidence of arrhythmic events, particularly of ventricular tachycardia, was observed in the first year after the index infarction. The presence or absence of an open infarct-related artery was the strongest independent predictor of these events, whereas other traditional risk factors, such as late potentials, were less helpful in identifying patients prone to sudden death. These findings emphasize the importance of the open artery hypothesis in patients recovering from acute myocardial infarction.
急性心肌梗死患者梗死相关动脉的成功再灌注已被证明可降低住院死亡率以及1年死亡率。除了溶栓诱导的心肌挽救外，越来越多的证据表明，开放的梗死相关动脉可提高心脏的电稳定性，且这种作用至少部分是这些患者长期预后良好的原因。然而，在溶栓时代的患者中，心肌梗死后第一年心律失常事件的确切发生率以及不同危险因素对这些并发症的预测价值尚未确定。
共有173例急性心肌梗死患者前瞻性地纳入本研究，其中51%接受了溶栓治疗。出院时，对所有患者进行了信号平均心电图、动态心电图监测、放射性核素血管造影、冠状动脉造影和左心室造影。136例患者记录到梗死相关动脉开放。晚期电位的总体发生率为24%（41例患者）。多因素分析显示，梗死相关动脉闭塞（P = 0.04）和存在局部室壁运动异常（P = 0.02）是晚期电位发生的最强独立预测因素。173例患者中有86例（50%）通过经皮冠状动脉腔内血管成形术或手术治疗残余缺血。70%的患者接受了β受体阻滞剂治疗。在平均12±5个月的随访期间，7例患者发生猝死或记录到心室颤动，而只有2例发生持续性单形性室性心动过速。总体1年死亡率为4.1%。多因素分析显示，只有梗死相关动脉闭塞是心律失常并发症的独立预测因素（P = 0.017）。
在按照当代治疗指南治疗的急性心肌梗死患者中，很大一部分患者接受了冠状动脉血运重建，在首次心肌梗死后的第一年观察到心律失常事件，特别是室性心动过速的发生率较低。梗死相关动脉是否开放是这些事件的最强独立预测因素，而其他传统危险因素，如晚期电位，在识别易发生猝死的患者方面帮助较小。这些发现强调了开放动脉假说在急性心肌梗死恢复患者中的重要性。
