急性心肌梗死行经皮腔内冠状动脉成形术及支架术前静脉溶栓与否的临床比较

Study on the clinical efficacy of immediate PTCA and primary intracoronary stent after intravenous rt-PA thrombolytic therapy in acute myocardial infarction

目的 :比较rt PA(5 0mg)静脉溶栓后即刻行经皮腔内冠状动脉成形术 (PTCA)与直接冠状动脉支架术治疗急性心肌梗死 (AMI)的临床疗效。方法 14 0例AMI患者 ,随机分为A、B两组。A组 75例行rt PA半量 (5 0mg)静脉溶栓后即刻行冠状动脉造影 (CAG)、PTCA及冠状动脉支架术。B组 6 5例直接行CAG、PTCA及冠状动脉支架术。术后观察 2 0d。结果 :①首次冠状动脉造影显示 :A组梗死相关动脉 (IRA) 83支 ,开通率 5 2 % ;B组IRA 71支 ,开通率 15 %。两组开通率相比差异有非常显著性意义 (P <0 .0 1)。②A、B两组行PTCA加支架置入术后IRA恢复TIMIⅢ级血流效果基本相同 ,A组 10 0 % ,B组 98.6 % ,两者相比差异无显著性意义 (P >0 .0 5 )。③患者住院 10～ 2 0d ,二维超声心动图显示 ,左室射血分数达到或超过 6 0 %者 ,A组为 94 .7% ,而B组仅占 4 3.9%。两者相比差异有显著性意义 (P <0 .0 5 )。④脑卒中或大出血并发症两组病例均未发生。⑤住院病死率 ,A组 4 .0 % (3/ 75 ) ,B组 3.1% (2 / 6 5 ) ,两者相比差异无显著性意义 (P >0 .0 5 )。结论 :A组较B组具有更早地使IRA前向血流再灌注 ,从而具有较好的左室保护功能 ,且不增加不良事件的发生。

Objective:To study the clinical efficacy of immediate percutaneous transluminal coronary angioplasty (PTCA) and primary intracoronary stenting after intravenous thrombolytic therapy using recombinant tissue plasminogen activator (rt PA) in patients with acute myocardial infarction (AMI).Method:From January 1998 to July 2001, one hundred and forty consecutive patients with AMI were divided into two groups. In group A, 75 patients received intravenous thrombolytic therapy using rt PA 50 mg before they had coronary aniography (CAG), PTCA and primary intracoronary stenting. In group B, 65 cases only received CAG, PTCA and primary intracoronary stenting. Left ventricular ejection was measured by two dimensional echocardiography and cardiac events were recorded during follow up.Result:①The first CAG when patients received cardiac catheterization showed that the re open rate of infarct related artery (IRA) in group A was 52% , while that in group B was 15%. The difference between group A and group B was significant (P< 0.01 ).②The re open rate of IRA in operated PTCA and stenting in group A and B was similar ( group A 100%; group B 98.6 % ). ③ At 20 days follow up, the left ventricular ejection fraction reached or exceeded 60% in group A was 95%, while that in group B was 44%. The difference between group A and group B was significant (P< 0.05 ). ④No complications of cerebral hemorrhage and hemorrhage were found in group A and group B .⑤ The mortality in hospital in group A was 4%, While that in group B was 3% , The difference between group A and group B was insignificant (P> 0.05 ).Conclusion:Comparison of the clinical curative effect between previous intravenous rt PA plus percutaneous coronary intervention (PCI) and PCI alone in AMI shows that the former method can reopen IRA earlier, decrease the complication in the operation of intracoronary stenting, protects the left ventricular ejection fraction more effectively and does not increase heart events happening.