急性心肌梗死药物溶栓后早期介入治疗

Combination treatment in acute myocardial infarction-thrombolysis and immediate early PTCA in acute myocardial infarction

目的 直接经皮冠状动脉腔内成形术 (PTCA)为急性心肌梗死 (AMI)提供了积极的有效的又安全的恢复心肌灌注的手段 ,优于常规溶栓治疗 ,但直接PTCA仍有时间延误问题。本研究旨在探讨AMI患者在等待PTCA时间延误期内 ,使用常规治疗剂量短效溶栓剂 (rt PA)治疗 ,促使梗死相关动脉(IRA)早期开通的有效性 ,及溶栓后立即进行加速PTCA可行性和安全性。方法 75例AMI患者用阿司匹林和肝素后接受rt PA 2 0mg 1次团注 ,随后 80mg半小时内快速滴入 ,尽快行急诊冠状动脉造影术 ,对IRA行PTCA或支架植入术 ,如果血管开通 ,仍有残余狭窄 ,亦行PTCA及支架术 ,和同期进行 88例AMI直接PTCA进行对比分析。本试验终点包括 ,到达导管室血管开通率 ,PTCA的结果 ,治疗后导管室血管开通率 ,PTCA的结果 ,治疗后 2周内左室功能及不良事件发生率。结果 到达导管室时 ,联合治疗 (溶栓加PTCA)血管开通率 88% (2 6 %TIMIⅡ级 ,6 2 %TIMIⅢ级血流 ) ,直接PTCA组为 36 % (2 0 %为TIMIⅡ级血流 ,16 %TIMIⅢ级血流 ) (P <0 .0 0 1)两组PTCA血流再通率相似 ,分别为 96 %、94 %。对IRA恢复TIMIⅢ级血流效果相同 ,分别为 84 % ,82 %。 2周内左室功能 (超声法EF)联合治疗组优于PTCA组(6 5 .4 % ,5 4 .6 % ,P <0 .0 5 )

Objective The study evaluated the efficiency and safety of a short-acting full-dose fibfinolytic regimen to promote early infarct-related artery (IRA) patency during the inherent delay experienced by infarction patients referred for angioplasty as the principal recanalization modality. Method Accepted aspirin and heparin, 75 patients were treated by an intravenous bolus of 20 mg recombined tissue-type plasminogen activator (rt-PA), then followed by 80 mg over 30 minutes. Patients were to undergo angiography as soon as possible following study drug. If the IRA was occlude (TIMI flow grade 0 or 1),or was open but with ≥50% stenosis, immediate early PTCA at the same time. The end point included patency rates on catheterzation laboratory (cath Lab) arrival, technical results when PTCA was performed, complication rates, clinical adverse events rates and left ventricular (LV) function by treatment assignment in two weeks. Results Patency on Cath lab arrival was 88% with combination treatment group (26% Thrombolysis in myocardia infarction trial TIMI-2, 66%TIMI-3), and 36%with primary PTCA group (20%TIMI-2, 16%TIMI-3), (P<0.001). The PTCA or stenting success rates were 96%(combination treatment), and 94%(primary PTCA). Immediate facilitated and primary PTCA restored TIMI-3 in infarct-related artery equally (84%, 82%). No differences were observed in stroke or major bleeding. Patients with primary PTCA mean convalescent ejection fraction(EF) was 54.6%, significantly lower than combination treatment patients 65.4%,(P<0.005). Conclusion the present trial has demonstrated that a short-acting full-dose of rt-PA produces more frequent early patency advantage occurring before a mechanical reperfusion attempt can be mediated (before cath arrival),with facilitates greater LV function preservation with no augmentation of adverse events).