Koenig W, Löwel H, Lewis M, Hörmann A
Department of Internal Medicine II---Cardiology, University of Ulm, Germany.
Eur Heart J. 1996 Aug;17(8):1199-206. doi: 10.1093/oxfordjournals.eurheartj.a015037.
A large number of randomized clinical trials have shown that thrombolysis, long-term treatment with beta-blockers, antiplatelet drugs, and angiotensin converting enzyme inhibitors improve survival after acute myocardial infarction (AMI). However, for calcium channel blockers (nifedipine, diltiazem, and verapamil) there was either no benefit, or positive effects have been reported in subgroups only. Recent studies have raised concern about the safety of this drug class, especially in patients with coronary heart disease. We studied the long-term survival, for a median follow-up time of 4.4 years, of 1197 non-diabetic patients in the population-based AMI registry in Augsburg, Germany, aged 25-74 years, who had survived a first Q wave acute myocardial infarction for at least 28 days. The impact of thrombolysis and prescribed medication at discharge (beta-blockers, antiplatelet drugs, and calcium channel blockers) on long-term survival was analysed using the Cox-Proportional-Hazard model, controlling for age, sex, and concomitant cardiac drug use. Thrombolysis (risk ratio, RR, 0.72; 95% confidence interval, CI, 0.48-1.08), long-term beta-blockade (RR 0.52; 95% CI 0.36-0.74) and antiplatelet drug use (RR 0.69; 95% CI 0.50-0.94) were associated with considerable reductions in total mortality. The use of calcium channel blockers was not associated with a reduction in total mortality (RR 1.23; 95% CI 0.89-1.69). Separate analyses for nifedipine (RR 1.00; 95% CI 0.68-1.48), and diltiazem (RR 1.55; 95% CI 1.04-2.32) showed an increased risk of death associated with the latter. Using patients on beta-blockers only (RR 1.00) as a reference, the prescription of these calcium channel blockers was consistently associated with an increased total mortality (nifedipine, without beta-blockers RR 1.20; 95% CI 1.12-3.57, diltiazem, without beta-blockers RR 2.87; 95% CI 1.75-4.70). These results from an observational study demonstrate a benefit of thrombolysis, beta-adrenergic blockade and antiplatelet drug use on long-term survival in acute myocardial infarction patients. Calcium channel blocker use appears to be associated with an increased risk of death. These data support the need for controlled trials to address this issue specifically.
大量随机临床试验表明，溶栓治疗、β受体阻滞剂长期治疗、抗血小板药物以及血管紧张素转换酶抑制剂可提高急性心肌梗死（AMI）后的生存率。然而，对于钙通道阻滞剂（硝苯地平、地尔硫䓬和维拉帕米），要么没有益处，要么仅在亚组中报告有积极作用。近期研究引发了对这类药物安全性的担忧，尤其是在冠心病患者中。我们对德国奥格斯堡基于人群的AMI登记处的1197例非糖尿病患者进行了研究，这些患者年龄在25至74岁之间，首次Q波急性心肌梗死后存活至少28天，中位随访时间为4.4年。使用Cox比例风险模型分析了溶栓治疗和出院时开具的药物（β受体阻滞剂、抗血小板药物和钙通道阻滞剂）对长期生存的影响，并对年龄、性别和同时使用的心脏药物进行了控制。溶栓治疗（风险比，RR，0.72；95%置信区间，CI，0.48 - 1.08）、长期β受体阻滞剂治疗（RR 0.52；95% CI 0.36 - 0.74）和抗血小板药物的使用（RR 0.69；95% CI 0.50 - 0.94）与总死亡率的显著降低相关。钙通道阻滞剂的使用与总死亡率的降低无关（RR 1.23；95% CI 0.89 - 1.69）。对硝苯地平（RR 1.00；95% CI 0.68 - 1.48）和地尔硫䓬（RR 1.55；95% CI 1.04 - 2.32）的单独分析显示，后者与死亡风险增加相关。以仅使用β受体阻滞剂的患者（RR 1.00）作为参照，这些钙通道阻滞剂的处方始终与总死亡率增加相关（硝苯地平，不使用β受体阻滞剂RR 1.20；95% CI 1.12 - 3.57，地尔硫䓬，不使用β受体阻滞剂RR 2.87；95% CI 1.75 - 4.70）。这项观察性研究的结果表明，溶栓治疗、β肾上腺素能阻滞剂和抗血小板药物的使用对急性心肌梗死患者的长期生存有益。钙通道阻滞剂的使用似乎与死亡风险增加相关。这些数据支持需要进行对照试验来专门解决这个问题。
