Ellis S G, Lincoff A M, George B S, Kereiakes D J, Ohman E M, Krucoff M W, Califf R M, Topol E J
Cleveland Clinic Foundation, OH 44195.
Coron Artery Dis. 1994 Jul;5(7):611-5. doi: 10.1097/00019501-199407000-00009.
Patients who have suffered acute myocardial infarction (AMI) and have been treated with intravenous thrombolytic agents resulting in early 'patent' [Thrombolysis in Myocardial Infarction (TIMI) 2-3 flow grade] arteries have been shown not to benefit from early percutaneous transluminal coronary angioplasty (PTCA). Recent data, however, suggest that the clinical outcome of patients with early TIMI 2 flow is decidedly inferior to that of patients with TIMI 3 flow, raising the question whether early PTCA might be beneficial for patients with TIMI 2 flow. The clinical utility of PTCA for this particular subset of patients has never been assessed.
We analyzed left ventricular ejection fraction (LVEF) recovery by contrast ventriculography and clinical outcome in Thrombolysis and Angioplasty in Myocardial Infarction Phase I (TAMI-I) study patients with initial TIMI 2 flow grade, determined by blinded core laboratory analysis.
No differences were observed between baseline demographic data for the 49 patients randomly assigned to undergo early PTCA compared with that from the 59 patients randomly assigned to receive early medical therapy. Patients were 56 +/- 11 years of age (mean +/- SD), 80% were men, the time from onset of chest pain to catheterization was 268 +/- 71 min, 42% had anterior AMI, and 42% had multivessel disease. Ninety minute baseline LVEF to prehospital discharge LVEF was minimally better in the group randomly assigned to undergo PTCA (51 +/- 12 to 52 +/- 11% versus 55 +/- 10 to 53 +/- 12%, P = 0.06). This contrasted with findings in patients with TIMI 3 flow grade at baseline, which showed a relative benefit for patients randomly assigned to receive early medical therapy (54 +/- 10 to 54 +/- 8% for PTCA, versus 55 +/- 10 to 58 +/- 8% for medical therapy, P = 0.01). Among patients with TIMI 2 flow grade there were no differences in in-hospital death or congestive heart failure (6.1 versus 1.7%, P = 0.25 and 18.4 versus 23.7%, P = 0.50, PTCA versus medical therapy, respectively).
We conclude that (1) PTCA of infarct-related arteries with TIMI 2 flow grade may modestly improve recovery of left ventricular function, and (2) widespread application of PTCA in this setting should be deferred, pending demonstration that this benefit outweighs the risks of PTCA.
急性心肌梗死（AMI）患者接受静脉溶栓治疗后早期血管达到“通畅”状态（心肌梗死溶栓治疗（TIMI）2 - 3级血流），此类患者未被证明能从早期经皮冠状动脉腔内血管成形术（PTCA）中获益。然而，近期数据表明，早期TIMI 2级血流患者的临床结局明显劣于TIMI 3级血流患者，这引发了一个问题，即早期PTCA对TIMI 2级血流患者是否有益。PTCA对于这一特定患者亚组的临床效用从未得到评估。
我们通过对比心室造影分析了心肌梗死溶栓与血管成形术I期（TAMI - I）研究中初始TIMI 2级血流患者的左心室射血分数（LVEF）恢复情况及临床结局，由盲法核心实验室分析确定。
随机分配接受早期PTCA的49例患者与随机分配接受早期药物治疗的59例患者相比，基线人口统计学数据无差异。患者年龄为56±11岁（均值±标准差），80%为男性，从胸痛发作到导管插入术的时间为268±71分钟，42%有前壁AMI，42%有多支血管病变。随机分配接受PTCA的组从基线90分钟LVEF到出院前LVEF略有改善（51±12%至52±11%，而55±10%至53±12%，P = 0.06）。这与基线时TIMI 3级血流患者的结果形成对比，后者显示随机分配接受早期药物治疗的患者有相对益处（PTCA组为54±10%至54±8%，药物治疗组为55±10%至58±8%，P = 0.01）。在TIMI 2级血流患者中，住院死亡或充血性心力衰竭无差异（分别为6.1%对1.7%，P = 0.25；18.4%对23.7%，P = 0.50，PTCA组对药物治疗组）。
我们得出结论：（1）对TIMI 2级血流的梗死相关动脉进行PTCA可能适度改善左心室功能的恢复；（2）在证明这种益处超过PTCA风险之前，应推迟在这种情况下广泛应用PTCA。
