Phibbs B, Marcus F, Marriott H J, Moss A, Spodick D H
Kino Community Hospital and the University of Arizona, Tucson, USA.
J Am Coll Cardiol. 1999 Feb;33(2):576-82. doi: 10.1016/s0735-1097(98)00593-2.
The whole subject can thus be summed up in two statements. 1. Every appropriately designed study comparing first Q and NQMI's has found no difference in post-MI course of the two categories and no foundation for the common notion that the NQMI is a uniquely "unstable" entity, to be classed with unstable angina in terms of prognosis and management. Nine such studies have been published. On the other hand, all studies alleging the "unstable" character of the NQMI have been invalidated by major flaws, chief among them the comparison of undifferentiated mixtures of first and subsequent infarcts with widely differing mortality and morbidity. This confusion is further compounded by the fact that subsequent infarcts generate Qwaves less than half as often as first infarcts. 2. All current studies indicate that there is no benefit to an invasive as compared with a conservative protocol for management of NQMI. Since the characterization of an infarct as "non-Q' conveys no therapeutic implications, the classification becomes irrelevant and should be discarded. Two quotations sum the whole matter succinctly. Moss (63) commented that "The Q-wave versus non-Q-wave categorization does not provide sufficient sensitivity, specificity, or predictive accuracy about the subsequent clinical course of patients with a first myocardial infarction to use it as reliable data in the clinical decision-making process." Surawicz (64) put the matter even more concisely: ". . . a non-Qwave MI is not a unique entity: rather it is a smaller and less extensive MI." In a word, the magnitude of a myocardial infarction should be judged on anatomical and functional considerations rather than on the designation of Qwave versus non-Qwave infarction.
因此，整个问题可以归纳为两点。1. 每一项设计合理、比较首次Q波心肌梗死（QMI）和非Q波心肌梗死（NQMI）的研究都发现，这两类患者心肌梗死后的病程没有差异，也没有依据支持将NQMI视为一种独特的“不稳定”实体的普遍观点，即从预后和治疗角度来看，应将其归为不稳定型心绞痛。已有九项此类研究发表。另一方面，所有声称NQMI具有“不稳定”特征的研究都因重大缺陷而无效，其中最主要的缺陷是将首次梗死和后续梗死的未分化混合样本进行比较，而这些样本的死亡率和发病率差异很大。后续梗死产生Q波的频率不到首次梗死的一半，这一事实进一步加剧了这种混淆。2. 目前所有研究表明，与保守治疗方案相比，对NQMI进行侵入性治疗并无益处。由于将梗死定义为“非Q波”没有治疗意义，因此这种分类变得无关紧要，应该摒弃。有两段话简洁地概括了整个问题。莫斯（63）评论道：“Q波与非Q波的分类对于首次心肌梗死患者的后续临床病程，在敏感性、特异性或预测准确性方面都不足，无法在临床决策过程中作为可靠数据使用。”苏拉维茨（64）说得更简洁：“……非Q波心肌梗死并非独特实体，而是面积更小、范围更局限的心肌梗死。”总之，判断心肌梗死的严重程度应基于解剖学和功能方面的考虑，而非Q波梗死与非Q波梗死的划分。
