Ribichini F, Steffenino G, Dellavalle A, Ferrero V, Vado A, Feola M, Uslenghi E
Division of Cardiology, Ospedale Santa Croce, Cuneo, Italy.
J Am Coll Cardiol. 1998 Nov 15;32(6):1687-94. doi: 10.1016/s0735-1097(98)00446-x.
The aim of the study was to compare randomly assigned primary angioplasty and accelerated recombinant tissue plasminogen activator (rt-PA), in patients with "high-risk" inferior acute myocardial infarction (ST-segment elevation in the inferior leads and ST-segment depression in the precordial leads).
The ST-segment depression in the precordial leads is a marker of severe prognosis in patients with inferior myocardial infarction. The comparative outcome of treatment with primary angioplasty or lysis with accelerated rt-PA has not been investigated.
One hundred and ten patients within 6 h of symptoms were randomized to either treatment. To assess the in-hospital and 1-year outcome of both treatments the following results were compared: death or nonfatal infarction, recurrence of angina, left ventricular ejection fraction (LVEF), and the need for repeat target vessel revascularization (TVR).
In patients treated with angioplasty (55) and rt-PA (55) the rate of in-hospital mortality and reinfarction was 3.6% versus 9.1% (p=0.4). Recurrence of angina was 1.8% versus 20% (p=0.002), new TVR was used in 3.6% versus 29.1% (p=0.0003), and the LVEF (%) at discharge was 55.2+/-9.5 versus 48.2+/-9.9 (p=0.0001). There were no hemorrhagic strokes, no emergency coronary artery bypass graft (CABG) and identical (5.5%) need for blood transfusions. At 1 year, the incidence of death, reinfarction or repeat TVR was 11% in the percutaneous transluminal coronary angioplasty (PTCA) group versus 52.7% in the rt-PA group (log-rank 22.38, p < 0.0001).
Primary angioplasty is superior to accelerated rt-PA in terms of both myocardial preservation and reduction of in-hospital complications in patients with inferior myocardial infarction and precordial ST-segment depression. Primary angioplasty also yields a better long-term event-free survival.
本研究旨在比较随机分配接受直接血管成形术和加速重组组织型纤溶酶原激活剂（rt-PA）治疗的“高危”下壁急性心肌梗死（下壁导联ST段抬高且胸前导联ST段压低）患者的疗效。
胸前导联ST段压低是下壁心肌梗死患者预后严重的一个标志。直接血管成形术或加速rt-PA溶栓治疗的比较结果尚未得到研究。
110例症状出现6小时内的患者被随机分配接受上述两种治疗之一。为评估两种治疗的院内及1年结局，比较了以下结果：死亡或非致死性梗死、心绞痛复发、左心室射血分数（LVEF）以及再次进行靶血管血运重建（TVR）的必要性。
接受血管成形术（55例）和rt-PA治疗（55例）的患者，院内死亡率和再梗死率分别为3.6%和9.1%（p = 0.4）。心绞痛复发率分别为1.8%和20%（p = 0.002），再次使用TVR的比例分别为3.6%和29.1%（p = 0.0003），出院时LVEF（%）分别为55.2±9.5和48.2±9.9（p = 0.0001）。未发生出血性卒中，未进行急诊冠状动脉旁路移植术（CABG），输血需求相同（5.5%）。1年时，经皮腔内冠状动脉成形术（PTCA）组死亡、再梗死或再次TVR的发生率为11%，而rt-PA组为52.7%（对数秩检验22.38，p < 0.0001）。
在伴有胸前导联ST段压低的下壁心肌梗死患者中，就心肌保护和减少院内并发症而言，直接血管成形术优于加速rt-PA。直接血管成形术还能带来更好的长期无事件生存率。
