Pilote L, Miller D P, Califf R M, Rao J S, Weaver W D, Topol E J
Montreal General Hospital, Quebec, Canada.
N Engl J Med. 1996 Oct 17;335(16):1198-205. doi: 10.1056/NEJM199610173351606.
Clinical trials and practice guidelines have identified clinical criteria for the use of coronary angiography and revascularization procedures after thrombolysis for acute myocardial infarction. The effect of these criteria on clinical practice has not been extensively evaluated.
We used classification-and-regression-tree (CART) and logistic-regression models to study the patients in the first Global Utilization of Streptokinase and Tissue Plasminogen Activator for Occluded Coronary Arteries trial, to identify the variables that best predicted the use of angiography and revascularization procedures after thrombolysis.
Among the 21,772 U.S. patients in the trial, 71 percent underwent coronary angiography before discharge from the hospital. Of these, 58 percent underwent revascularization (73 percent receiving angioplasty). The CART model for the use of angiography showed that age was the variable most predictive of angiography; only 53 percent of patients at least 73 years of age underwent angiography, as compared with 76 percent of those under 73. Among the older patients, age was again the most predictive factor; among the younger patients, the availability of angioplasty was a more important predictor (67 percent of patients in hospitals without angioplasty facilities underwent angiography, as compared with 83 percent in hospitals with such facilities). The next most important variable was recurrent ischemia, which was more predictive at hospitals without angioplasty facilities than at those with them. Both statistical models identified coronary anatomy as the most important predictor of the use and type of revascularization.
More patients treated with thrombolysis underwent angiography and revascularization before discharge than might be expected. Younger age and the availability of the procedures appeared to be the major determinants of the use of coronary angiography, whereas coronary anatomy largely determined the use and type of revascularization. This process appeared to select low-risk patients for intervention rather than those at higher risk, who would be the most likely to benefit.
临床试验和实践指南已经确定了急性心肌梗死溶栓治疗后冠状动脉造影和血运重建术使用的临床标准。这些标准对临床实践的影响尚未得到广泛评估。
我们使用分类回归树（CART）和逻辑回归模型研究了第一项全球应用链激酶和组织型纤溶酶原激活剂治疗闭塞冠状动脉试验中的患者，以确定最能预测溶栓后血管造影和血运重建术使用情况的变量。
在该试验的21772名美国患者中，71%在出院前接受了冠状动脉造影。其中，58%接受了血运重建（73%接受了血管成形术）。血管造影使用情况的CART模型显示，年龄是血管造影最具预测性的变量；73岁及以上的患者中只有53%接受了血管造影，而73岁以下的患者中这一比例为76%。在老年患者中，年龄仍然是最具预测性的因素；在年轻患者中，血管成形术的可及性是一个更重要的预测因素（没有血管成形术设施的医院中67%的患者接受了血管造影，而有此类设施的医院中这一比例为83%）。其次最重要的变量是复发性缺血，在没有血管成形术设施的医院中，其预测性比有此类设施的医院更高。两种统计模型均将冠状动脉解剖结构确定为血运重建术使用情况和类型的最重要预测因素。
接受溶栓治疗的患者在出院前接受血管造影和血运重建术的人数比预期的要多。年龄较小和这些手术的可及性似乎是冠状动脉造影使用的主要决定因素，而冠状动脉解剖结构在很大程度上决定了血运重建术的使用情况和类型。这一过程似乎选择了低风险患者进行干预，而不是那些最可能受益的高风险患者。
