依诺肝素两种用法联合瑞替普酶和尿激酶治疗AMI的疗效与安全性比较

To compare the efficacy and safety of two doses administration of Enoxaparin in patients with ST elevation myocardial infarction undergoing thrombolysis

目的 比较依诺肝素两种用法联合瑞替普酶（r-PA）与尿激酶（UK）静脉溶栓治疗急性ST段抬高型心肌梗死（STEMI）的疗效与安全性,探讨CRUSADE评分系统对溶栓出血风险评估的价值.方法 选择2010年6月至2014年3月我院CCU病房收治的183例首次STEMI接受溶栓治疗的患者,其中r-PA组121例,UK组62例.r-PA组按是否给予静脉依诺肝素负荷随机分为r-PA 1组（负荷组）61例、r-PA 2组（无负荷组）60例.依诺肝素用法：r-PA 1组溶栓前先静脉推注30 mg,溶栓结束后即刻1 mg/kg皮下注射;r-PA 2组溶栓前1 mg/kg皮下注射;之后两组均每12 h一次皮下注射,疗程5～8 d.选择同时间段应用UK治疗的62例STEMI患者定为UK组.比较三组患者溶栓30、60、90 min临床再通率及出血并发症.将183例患者进行CRUSADE评分,分析出血与评分的关系.结果 30、60、90 min临床再通率r-PA 1组为32.9％、75.4％、90.2％,r-PA 2组为13.3％、46.7％、78.3％,UK组为3.2％、16.1％、48.4％.r-PA 1组和r-PA 2组各时间段再通率均高于UK组,差异有统计学意义（P＜0.01）;r-PA 1组各时间段再通率均高于r-PA 2组,差异有统计学意义（P＜0.05）.出血发生率r-PA 1组为18.0％,r-PA 2组为16.7％,UK组为14.5％,三组比较未见统计学差异（P＞0.05）.CRUSADE评分≥32分者,溶栓后消化道出血及脑出血发生率（40.0％）明显高于32分以下的患者（7.0％）,差异有统计学意义（P＜0.01）.结论 瑞替普酶溶栓疗效明显优于尿激酶.瑞替普酶溶栓前静脉给予30 mg依诺肝素负荷量,可明显加快冠脉再通时间,提高再通率.应用CRUSADE评分对溶栓后消化道出血及脑出血具有良好的评估价值.

Objective To compare the efficacy and safety of two administration of Enoxaparin in patients with ST elevation myocardial infarction undergoing thrombolysis regardless of the choice of lytic,either Reteplase （r-PA） or Urokinase （UK）.To discuss the value of CRUSADE scoring system predicting bleeding risk in people undergoing thrombolysis.Methods 121 patients with STEMI were randomly divided into r-PA 1 group （61 cases）,r-PA 2 group（60 cases） enoxaparin usage in each group.r-PA 1 group：30 mg intravenous before thrombolysis and 1 mg/kg subcutaneous immediately after thrombolysis.R-PA 2 group：1 mg/kg subcutaneous before thrombolysis and then Q12 h subcutaneous,for 5-8 days.Select 62 patients with STEMI undergoing thrombolysis with UK as the UK group.Compare recanalization rate and incidence of major bleeding complications in three groups respectively at 30 min,60 min and 90 min.Calculate CRUSADE score of the total 183 patients,analyze correlation between bleeding and CRUSADE score.Results Recanalization rate at 30,60,90 min respectively in each group：32.9%,75.4%,32.9% in r-PA1 group.13.3%,46.7%,13.3% in r-PA2 group,and 3.2%,16.1%,3.2% in the UK group.Both r-PA1 group and r-PA2 group had higher recanalization rate than UK group at each point-in-time （P〈0.01）.The recanalization rate in r-PA1 group was higher than in r-PA2 group at each point-in-time （P〈0.05）.There was no statistically significant difference about the incidence of bleeding among three groups （P〉0.05）.Patients with CRUSADE score higher than 32 had more intracerebral and gastrointestinal hemorrhage events associated with thrombolysis than patients with CRUSADE score lower than 32（P〈0.01）.Condusion Reteplase was more effective than urokinase in patients undergoing thrombolysis.Administration of enoxaparin 30 mg before thrombolysis could obviously accelerate the recanalization,improve recanalization rate.CRUSADE score had predictive value for intracerebral or gastrointestinal hemorrhage associated with thrombolysis.