Krucoff M W, Croll M A, Pope J E, Granger C B, O'Connor C M, Sigmon K N, Wagner B L, Ryan J A, Lee K L, Kereiakes D J
Department of Medicine, Duke University Medical Center, Durham, NC 27710.
Circulation. 1993 Aug;88(2):437-46. doi: 10.1161/01.cir.88.2.437.
If a practical, reliable, noninvasive marker of failed reperfusion was available in real time, the benefits of further therapy in this patient subgroup could be tested. We developed a method of 12-lead ST-segment recovery analysis using continuously updated reference points to provide such a marker.
In this study, our method was prospectively tested in 144 patients given thrombolytic therapy early in myocardial infarction. All patients had 12-lead continuous ST-segment monitoring and acute angiography, each analyzed in an independent, blinded core laboratory. ST-segment recovery and re-elevation were analyzed up to the moment of angiography, at which time patency was predicted. Predictions were correlated to angiographic infarct artery flow, with TIMI flow 0 to 1 as occluded and TIMI flow 2 to 3 as patent. Infarct artery occlusion was seen on first injection in 27% of patients. The positive predictive value of incomplete ST recovery or ST re-elevation by our method was 71%, negative predictive value 87%, with 90% specificity and 64% sensitivity for coronary occlusion. ST recovery analysis predicted patency in 94% of patients with TIMI 3 flow versus 81% of patients with TIMI 2 flow and predicted occlusion in 57% of patients with collateralized occlusion versus 72% of patients with non-collateralized occlusion. In a regression model including other noninvasive clinical descriptors, ST recovery alone contained the vast majority of predictive information about patency.
In a blinded, prospective, angiographically correlated study design, 12-lead continuous ST-segment recovery analysis shows promise as a practical noninvasive marker of failed reperfusion that may contribute substantially to currently available bedside assessment. Our data also suggest that patients with TIMI 2 flow or with collateralized occlusions may represent a physiological spectrum definable with ST-segment recovery analysis.
如果能实时获得一个实用、可靠的再灌注失败的非侵入性标志物，就可以对这一患者亚组进行进一步治疗的益处进行检验。我们开发了一种使用连续更新参考点的12导联ST段恢复分析方法来提供这样一个标志物。
在本研究中，我们的方法在144例心肌梗死早期接受溶栓治疗的患者中进行了前瞻性测试。所有患者均进行12导联连续ST段监测和急性血管造影，每项检查均在独立的、盲法核心实验室进行分析。在血管造影时分析ST段恢复和再抬高情况，并预测血管通畅情况。预测结果与血管造影梗死动脉血流相关，TIMI血流0至1为闭塞，TIMI血流2至3为通畅。27%的患者首次注射时可见梗死动脉闭塞。我们的方法对ST段恢复不完全或ST段再抬高的阳性预测值为71%，阴性预测值为87%，对冠状动脉闭塞的特异性为90%，敏感性为64%。ST段恢复分析预测TIMI 3级血流患者血管通畅率为94%，TIMI 2级血流患者为81%，预测侧支循环闭塞患者闭塞率为57%，非侧支循环闭塞患者为72%。在一个包含其他非侵入性临床描述指标的回归模型中，仅ST段恢复就包含了关于血管通畅的绝大多数预测信息。
在一项盲法、前瞻性、血管造影相关的研究设计中，12导联连续ST段恢复分析显示有望成为一种实用的再灌注失败的非侵入性标志物，可能对目前可用的床边评估有很大帮助。我们的数据还表明，TIMI 2级血流或侧支循环闭塞的患者可能代表了一个可用ST段恢复分析定义的生理谱。
