Midgette A S, Wong J B, Beshansky J R, Porath A, Fleming C, Pauker S G
Department of Medicine, Cleveland VAMC, OH 44106.
Med Decis Making. 1994 Apr-Jun;14(2):108-17. doi: 10.1177/0272989X9401400203.
To determine the effects of infarct location and of the likelihood of infarction on the cost-effectiveness of intravenous streptokinase (IVSK) for suspected acute myocardial infarction (AMI).
A meta-analysis of short-term survival was combined with a simple decision tree to determine marginal cost-effectiveness ratios for different infarct locations and different likelihoods of AMI (pMI).
Six randomized trials comparing IVSK with conservative treatment.
31,940 patients with onset of symptoms of AMI from four to 24 hours earlier and, with the exception of one trial, electrocardiographic abnormalities. Patients with contraindications to thrombolytic treatment such as uncontrolled hypertension were excluded.
If AMI is certain, treatment with IVSK has marginal cost-effectiveness ratios for each additional life saved of $9,900, $56,600, and $28,400, respectively, for patients with anterior, inferior, and other locations of AMI. If pMI is 50% treatment with IVSK has marginal cost-effectiveness ratios for each additional life saved of $22,700, $131,800, and $63,100, respectively, for patients with anterior, inferior, and other locations of AMI.
The marginal cost-effectiveness ratio for IVSK therapy of inferior infarction is six times that for anterior infarction and rises steeply as the presence of AMI becomes less certain. Assuming society is willing to pay $250,000 per life saved, IVSK therapy should be given if the chance of acute anterior infarction exceeds 7%, if the chance of inferior infarction exceeds 32%, or if the chance of infarction in other locations exceeds 17%. In patients with suspected acute myocardial infarction, IVSK saves lives and is a reasonable use of societal resources.
确定梗死部位以及梗死可能性对静脉注射链激酶（IVSK）治疗疑似急性心肌梗死（AMI）成本效益的影响。
短期生存的荟萃分析与简单决策树相结合，以确定不同梗死部位和不同AMI可能性（pMI）的边际成本效益比。
六项比较IVSK与保守治疗的随机试验。
31940例患者，症状发作时间为4至24小时前，除一项试验外均有心电图异常。排除有溶栓治疗禁忌证（如未控制的高血压）的患者。
如果AMI确诊，对于前壁、下壁和其他部位AMI患者，IVSK治疗每多挽救一条生命的边际成本效益比分别为9900美元、56600美元和28400美元。如果pMI为50%，对于前壁、下壁和其他部位AMI患者，IVSK治疗每多挽救一条生命的边际成本效益比分别为22700美元、131800美元和63100美元。
下壁梗死IVSK治疗的边际成本效益比是前壁梗死的六倍，且随着AMI可能性降低而急剧上升。假设社会愿意为每条挽救的生命支付250000美元，那么如果急性前壁梗死的可能性超过7%、下壁梗死的可能性超过32%或其他部位梗死的可能性超过17%，就应给予IVSK治疗。在疑似急性心肌梗死患者中，IVSK可挽救生命，是对社会资源的合理利用。
