静脉溶栓联合早期经皮冠状动脉介入治疗急性ST段抬高型心肌梗死的荟萃分析

A meta-analysis of early percutaneous coronary intervention within 24 hours of thrombolysis in acute ST-elevation myocardial infarction

目的 系统评价静脉溶栓联合早期经皮冠状动脉介入（PCI）治疗急性ST段抬高心肌梗死（24 h）的有效性和安全性.方法 计算机检索MEDLINE、EMBASE、Elsevier、Cochrane数据库及中国万方、中国知网（CNKI）数据库,收集静脉溶栓联合早期PCI治疗急性ST段抬高心肌梗死的随机对照试验（RCT）,2名研究者独立检索和评价相关文献,应用RevMan 5.0和Stata 10.0软件进行数据统计学处理.结果 共纳入8项研究（NORDI-STEMI,TRANSFER-AMI,WEST,CARESS-AMI,CAPITAL-AMI,GRACIA-Ⅰ,SIAMI Ⅲ,PRAGUE-Ⅰ）,3157例病人.（1） 溶栓后早期PCI治疗组30d复合终点事件低于对照组（RR=0.52,95％CI 0.42～0.65,P〈0.001）;（2）溶栓后早期PCI治疗组30 d非致死性心肌梗死发生率低于对照组（RR=0.57,95％CI 0.40～0.81,P=0.002）;（3） 溶栓后早期PCI治疗组30 d再发心肌缺血发生率低于对照组（RR=0.27,95％CI 0.14～0.52,P〈0.001）;（4） 溶栓后早期PCI治疗组30 d出血并发症发生率（RR=1.07,95％CI 0.78～1.46,P=0.69）、30d心血管性死亡发生率（RR=0.86,95％CI 0.62～1.20,P=0.38）,组间比较差异无统计学意义.结论 静脉溶栓联合早期PCI治疗急性ST段抬高心肌梗死能够降低30 d复合终点事件、非致死性心肌梗死发生率和再发心肌缺血发生率,而不增加出血和死亡风险.

Objective To evaluate the efficacy and safety of early percutaneous coronary intervention （PCI） within 24 hours of thrombolysis in acute ST-elevation myocardial infarction. Methods The databases of Medline, EMBASE, Elsevier, Cochrane library, Wanfang and CNKI were searched for randomized controlled trials. Quality assessment and data extraction were performed by two independent reviewers. Statistical analyses were conducted with Stata 10.0 and RevMan 5.0 software. Results Eight studies （NORDI-STEMI, TRANSFER-AMI, WEST, CARESS-AMI, CAPITAL-AMI, GRACIA-Ⅰ, SIAMI Ⅲ ＆ PRAGUE-Ⅰ） involving a total of 3157 patients fulfilled the inclusion criteria. Meta-analysis results showed that, as compared with the control group, （1） the combined endpoint of 30 day mortality, re-infarction and ischemia was significantly lower in early PCI within 24 h of thrombolysis group [relative risk （RR）=0.52, 95% confidence interval （CI）0.42-0.65, P〈0.001]; （2） 30-day re-infarction decreased in early PCI within 24 h of thrombolysis group （RR=0.57, 95% CI 0.40-0.81, P=0.002）; （3） 30-day ischemia had a significant reduction in early PCI within 24 h of thrombolysis group （RR=0.27, 95% CI 0.14-0.52, P〈0.001）; （4） 30-day major hemorrhage or mortality rates were not significantly different between two groups （RR=1.07, 95% CI 0.78-1.46, P=0.69; RR=0.86, 95% CI 0.62-1.20, P=0.38 respectively）. Conclusion When primary PCI is not feasible, our meta-analysis favors early PCI within 24 h of thrombolysis for acute ST-elevation myocardial infarction. Early PCI is associated with a lowered recurrence of major adverse cardiac events, ischemia and re-infarction. But there is no elevated risk of major hemorrhage and mortality.