Norris R M, White H D, Cross D B, Woo K S, Elliott J M, Twigden D, Williams B, Johnson R N
Cardiology Department, Green Lane Hospital, Auckland, New Zealand.
Br Heart J. 1993 Jun;69(6):485-91. doi: 10.1136/hrt.69.6.485.
To validate a simple noninvasive method with serial creatine kinase measurements for diagnosis of early patency of the infarct related artery after thrombolytic treatment with streptokinase. To investigate the relation between early patency of the infarct related artery and prognosis.
Patients under 76 years of age and seen within six hours of the start of prolonged chest pain and ST segment elevation were treated with streptokinase (1.5 x 10(6) U) intravenously over 30-60 minutes. Blood for measurement of total creatine kinase activity was taken at baseline and at 1, 2, 3, 4, 8, 12, 16, 20, and 24 hours after starting treatment. The rise in enzyme activity at each time from baseline was expressed as a proportion of the total rise from baseline to peak.
Patients studied were in the following groups: (a) Sixty patients took part in a validation study with angiographic determination of patency of the infarct related coronary artery at 2.6 (0.3) hours (mean (SD)) after starting streptokinase. (b) A further 258 patients did not have early arteriography, but data were added to those from the 60 validation patients to find the relation between enzymatically determined early patency of the infarct related artery and 30 day mortality. (c) A further subset of 232 patients with first infarctions (including patients from groups (a) and (b) had angiocardiography at three weeks after infarction, and data were used to investigate the relation between early patency of the infarct related artery and left ventricular function.
Normalised rate of rise of creatine kinase activity at three hours after starting streptokinase in relation to angiographic patency of the infarct related coronary artery at 2.5 hours; 30 day cardiac mortality; and left ventricular function at three weeks in survivors of first infarction.
In the validation study, a rise in three hour creatine kinase activity of > 20% of peak occurred in 34/37 patients with initially patent infarct related coronary arteries (sensitivity 92%), and a rise to < 20% of peak occurred in 21/23 patients with initially occluded arteries (specificity 91%). In the prognostic study, 30 day mortality was 2.1% in the 191 patients with three hour creatine kinase > 20% of peak and 8.7% in the 127 patients with three hour creatine kinase < 20% of peak (p < 0.01). Angiocardiography in three week survivors of anterior infarction (n = 95) showed better left ventricular function when three hour creatine kinase was > or = 20% than when it was < 20% of peak (mean (SEM) end systolic volume 71 (5) v 96 (9) ml, p < 0.02; ejection fraction 56% (2%) v 51% (2%), NS).
Non-invasive determination of early patency of the infarct related artery by the normalised rate of rise of creatine kinase activity at three hours seems to be reliable, and may be prognostically important and of value for use in clinical trials.
验证一种通过连续测定肌酸激酶来诊断链激酶溶栓治疗后梗死相关动脉早期开通情况的简单无创方法。研究梗死相关动脉早期开通与预后的关系。
年龄在76岁以下、在长时间胸痛和ST段抬高开始后6小时内就诊的患者，在30 - 60分钟内静脉注射链激酶（1.5×10⁶U）。在开始治疗后的基线、1、2、3、4、8、12、16、20和24小时采集血样测定总肌酸激酶活性。每次相对于基线的酶活性升高表示为从基线到峰值总升高的比例。
研究的患者分为以下几组：（a）60例患者参与了一项验证研究，在开始链激酶治疗后2.6（0.3）小时（均值（标准差））通过血管造影确定梗死相关冠状动脉的开通情况。（b）另外258例患者未进行早期血管造影，但将其数据与60例验证患者的数据相加，以寻找酶学测定的梗死相关动脉早期开通与30天死亡率之间的关系。（c）另外232例首次梗死患者的子集（包括（a）组和（b）组的患者）在梗死后3周进行了心血管造影，数据用于研究梗死相关动脉早期开通与左心室功能的关系。
开始链激酶治疗后3小时肌酸激酶活性的标准化升高率与2.5小时梗死相关冠状动脉血管造影开通情况的关系；第30天的心脏死亡率；首次梗死幸存者3周时的左心室功能。
在验证研究中，37例最初梗死相关冠状动脉开通的患者中有34例（敏感性92%）在3小时时肌酸激酶活性升高超过峰值的20%，2³例最初血管闭塞的患者中有21例（特异性91%）升高至峰值的20%以下。在预后研究中，191例3小时肌酸激酶超过峰值20%的患者第30天死亡率为2.1%，127例3小时肌酸激酶低于峰值20%的患者第30天死亡率为8.7%（p<0.01）。前壁梗死3周幸存者（n = 95）的心血管造影显示，3小时肌酸激酶≥峰值20%时左心室功能优于低于峰值20%时（平均（标准误）收缩末期容积71（5）对96（9）ml，p<0.02；射血分数56%（2%）对51%（2%），无显著性差异）。
通过3小时时肌酸激酶活性的标准化升高率进行梗死相关动脉早期开通的无创测定似乎是可靠的，在预后方面可能很重要，并且对临床试验有价值。
