Nee P A
Whiston Hospital, Prescot, Merseyside, United Kingdom.
J Accid Emerg Med. 1997 Jan;14(1):2-9. doi: 10.1136/emj.14.1.2.
Appropriate use of a thrombolytic agent may save 20 to 30 lives per 1000 treatments. Thrombolysis should be considered in all patients presenting with cardiac chest pain lasting more than 30 minutes for up to 12 hours after symptom onset. ECG criteria include ST elevation of at least 1 mm in limb leads and/or at least 2 mm in two or more adjacent chest leads or left bundle branch block. There is no upper age limit. All patients should also receive oral aspirin and subcutaneous (intravenous with rt-PA) heparin. Other adjuvant treatments have been reviewed previously in this journal. Streptokinase is the drug of choice except where there is persistent hypotension, previous streptokinase or APSAC at any time, known allergy to streptokinase, or a recent proven streptococcal infection. In these circumstances the patient should receive rt-PA. Additional indications for rt-PA, based on subset analysis by the GUSTO investigators, include patients with ALL of the following: age less than 75 years, presentation within four hours of symptom onset, and ECG evidence of anterior acute myocardial infarction. Treatment should be initiated as soon as possible. The greatest benefit is observed in patients treated early, pain to treat intervals of less than one hour make possible mortality reductions of nearly 50%. "When" matters more than "where": fast tracking to the CCU is one option but A&E initiated thrombolysis is feasible and timely. Prehospital thrombolysis is appropriate in certain geographical situations. The development of practical guidelines for thrombolysis represents the most comprehensive example of evidence based medicine. Streptokinase was first shown to influence outcome in acute myocardial infarction nearly 40 years ago. More recently alternative regimes have been evaluated in several prospective randomised controlled trials yielding pooled data on nearly 60,000 patients. However, systematic review of cumulative data reveals a statistically significant mortality gain for intravenous streptokinase over placebo which could have been identified as early as 1971-at least 15 years before it became generally used in clinical practice.
适当使用溶栓剂每1000次治疗可挽救20至30条生命。对于所有出现心脏性胸痛且症状发作后持续超过30分钟达12小时的患者，均应考虑溶栓治疗。心电图标准包括肢体导联ST段抬高至少1毫米和/或两个或更多相邻胸导联ST段抬高至少2毫米或左束支传导阻滞。没有年龄上限。所有患者还应接受口服阿司匹林和皮下（使用rt-PA时为静脉注射）肝素治疗。本刊之前已对其他辅助治疗进行过综述。除存在持续性低血压、既往曾在任何时间使用过链激酶或氨甲环酸纤溶酶原激活剂、已知对链激酶过敏或近期证实有链球菌感染的情况外，链激酶是首选药物。在这些情况下，患者应接受rt-PA治疗。根据GUSTO研究人员的亚组分析，rt-PA的其他适应证包括所有以下情况的患者：年龄小于75岁、症状发作后4小时内就诊且有前壁急性心肌梗死的心电图证据。应尽快开始治疗。在早期接受治疗的患者中观察到最大益处，疼痛至治疗间隔时间少于1小时可使死亡率降低近50%。“何时”比“何地”更重要：快速转至冠心病监护病房是一种选择，但在急诊科启动溶栓治疗是可行且及时的。在某些地理区域，院前溶栓是合适的。制定溶栓治疗实用指南是循证医学最全面的范例。近40年前首次证明链激酶可影响急性心肌梗死转归。最近，在几项前瞻性随机对照试验中对其他治疗方案进行了评估，得出了近60000例患者的汇总数据。然而，对累积数据的系统评价显示，静脉注射链激酶相对于安慰剂在统计学上有显著的死亡率降低，这早在1971年就已得到证实——至少在其普遍应用于临床实践前15年。
