Holmes D R, Califf R M, Van de Werf F, Berger P B, Bates E R, Simoons M L, White H D, Thompson T D, Topol E J
Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota 55905, USA.
Lancet. 1997 Jan 11;349(9045):75-8. doi: 10.1016/s0140-6736(96)03031-0.
Use of aggressive and invasive interventions is more common in the USA than in other countries. We have compared use of resources for patients with cardiogenic shock after myocardial infarction in the USA and in other countries, and assessed the association between use of resources and clinical outcomes.
We analysed data for patients with cardiogenic shock after myocardial infarction who were enrolled in the GUSTO-I trial (1891 treated in the USA, 1081 treated in other countries). Patients were randomly assigned combinations of streptokinase, heparin, and accelerated tissue-plasminogen activator (t-PA), then decisions about further interventions were left to the discretion of the attending physician. The interventions included in our analysis were: pulmonary-artery catheterisation, cardiac catheterisation, intravenous inotropic agents, ventilatory support, intra-aortic balloon counterpulsation (IABP), percutaneous transluminal coronary angioplasty (PTCA), and coronary bypass graft surgery (CABG). The primary outcome measure was death from any cause at 30 days of follow-up.
Patients who were treated in the USA were significantly younger than those treated elsewhere (median 68 [IQR 59-75] vs 70 [62-76], p < 0.001), a smaller proportion had anterior infarction (49 vs 53%, p < 0.001), and they had a shorter time to treatment (mean 3.1 vs 3.3 h, p < 0.001). Aggressive diagnostic and therapeutic procedures were used more commonly in the USA than in the other countries: cardiac catheterisation (58 vs 23%); IABP (35 vs 7%); right-heart catheterisation (57 vs 22%); and ventilatory support (54 vs 38%). 483 (26%) of the patients treated in the USA underwent PTCA, compared with 82 (8%) patients in other countries. Patients who underwent revascularisation had better survival in all countries. Adjusted 30-day mortality was significantly lower among patients treated in the USA than among those treated elsewhere (50 vs 66%, p < 0.001). The difference in mortality remained at 1 year-56% of patients treated in the USA died versus 70% of patients treated elsewhere (hazard ratio 0.69 [95% CI 0.63-0.75], p < 0.001).
30-day and 1-year mortality was significantly lower among patients treated in the USA than among those treated in other countries. This difference in mortality may be due to the greater use of invasive diagnostic and therapeutic interventions in the USA.
在美国，积极的和侵入性的干预措施的使用比其他国家更为普遍。我们比较了美国和其他国家心肌梗死后心源性休克患者的资源使用情况，并评估了资源使用与临床结局之间的关联。
我们分析了参加GUSTO-I试验的心肌梗死后心源性休克患者的数据（美国治疗1891例，其他国家治疗1081例）。患者被随机分配接受链激酶、肝素和加速组织型纤溶酶原激活剂（t-PA）的联合治疗，然后进一步干预的决策由主治医生自行决定。我们分析中包括的干预措施有：肺动脉导管插入术、心导管插入术、静脉注射正性肌力药物、通气支持、主动脉内球囊反搏（IABP）、经皮腔内冠状动脉成形术（PTCA）和冠状动脉搭桥手术（CABG）。主要结局指标是随访30天时任何原因导致的死亡。
在美国接受治疗的患者明显比在其他地方治疗的患者年轻（中位数68岁[四分位间距59 - 75岁]对70岁[62 - 76岁]，p < 0.001），前壁梗死的比例较小（49%对53%，p < 0.001），且治疗时间较短（平均3.1小时对3.3小时，p < 0.001）。在美国，积极的诊断和治疗程序比其他国家更常用：心导管插入术（58%对23%）；IABP（35%对7%）；右心导管插入术（57%对22%）；以及通气支持（54%对38%）。在美国接受治疗的患者中有483例（26%）接受了PTCA，而其他国家为82例（8%）。在所有国家，接受血运重建的患者生存率更高。在美国接受治疗的患者30天调整后死亡率显著低于其他地方治疗的患者（50%对66%，p < 0.001）。死亡率差异在1年时仍然存在——在美国接受治疗的患者中有56%死亡，而其他地方治疗的患者中有70%死亡（风险比0.69[95%置信区间0.63 - 0.75]，p < 0.001）。
在美国接受治疗的患者30天和1年死亡率显著低于其他国家治疗的患者。这种死亡率差异可能是由于美国更多地使用侵入性诊断和治疗干预措施。
