Mahaffey K W, Granger C B, Collins R, O'Connor C M, Ohman E M, Bleich S D, Col J J, Califf R M
Department of Medicine, Duke University Medical Center, Durham, North Carolina 27710, USA.
Am J Cardiol. 1996 Mar 15;77(8):551-6. doi: 10.1016/s0002-9149(97)89305-8.
Intravenous heparin is routinely given after thrombolytic therapy for patients with acute myocardial infarction in the United States and in some, but by no means all, other countries. Several trials have documented improved infarct-artery patency in patients treated with heparin; however, none was large enough individually to assess the effect of heparin on clinical outcomes. We performed a systematic overview of the 6 randomized controlled trials (1,735 patients) to summarize the available data concerning the risks and benefits of intravenous heparin versus no heparin after thrombolytic therapy. Mortality before hospital discharge was 5.1% for patients allocated to intravenous heparin compared with 5.6% for controls (relative risk reduction of 9%, odds ratio 0.91, 95% confidence interval 0.59 to 1.39). Similar rates of recurrent ischemia and reinfarction were observed among those allocated to heparin therapy or control. The rates of total stroke, intracranial hemorrhage, and severe bleeding were similar in patients allocated to heparin; however, the risk of any severity of bleeding was significantly higher (22.7% vs 16.2%; odds ratio 1.55, 95% confidence interval 1.21 to 1.98). There was no significant difference in the observed effects of heparin between patients receiving tissue-type plasminogen activator and those receiving streptokinase or anisoylated plasminogen streptokinase activator complex, or between patients who did and did not receive aspirin. The findings of this overview demonstrate that insufficient clinical outcome data are available to support or to refute the routine use of intravenous heparin therapy after thrombolysis. It is not known if these findings are due to lack of statistical power, inappropriate levels of anticoagulation, or lack of benefit of intravenous heparin. Large randomized studies of heparin (and of new antithrombotic regimens) are needed to establish the role of such therapy.
在美国以及其他一些（但绝非全部）国家，急性心肌梗死患者接受溶栓治疗后通常会静脉注射肝素。多项试验记录了接受肝素治疗的患者梗死动脉通畅情况有所改善；然而，没有一项试验规模大到足以单独评估肝素对临床结局的影响。我们对6项随机对照试验（1735例患者）进行了系统综述，以总结有关溶栓治疗后静脉注射肝素与不使用肝素的风险和益处的现有数据。分配接受静脉注射肝素的患者出院前死亡率为5.1%，而对照组为5.6%（相对风险降低9%，优势比0.91，95%置信区间0.59至1.39）。在接受肝素治疗或对照组的患者中，复发性缺血和再梗死的发生率相似。分配接受肝素治疗的患者中，总卒中、颅内出血和严重出血的发生率相似；然而，任何严重程度出血的风险显著更高（22.7%对16.2%；优势比1.55，95%置信区间1.21至1.98）。接受组织型纤溶酶原激活剂的患者与接受链激酶或茴香酰化纤溶酶原链激酶激活剂复合物的患者之间，以及接受阿司匹林和未接受阿司匹林的患者之间，肝素的观察效果没有显著差异。该综述的结果表明，没有足够的临床结局数据来支持或反驳溶栓后常规使用静脉肝素治疗。尚不清楚这些结果是由于缺乏统计效力、抗凝水平不当还是静脉肝素缺乏益处。需要对肝素（以及新的抗血栓治疗方案）进行大型随机研究，以确定此类治疗的作用。
