治疗延迟对急性心肌梗死直接经皮冠状动脉介入治疗预后的影响:来自CADILLAC试验的分析

Background: The impact of treatment delays on outcomes after primary percutaneous coronary intervention for acute myocardial infarction is controversial. Methods: The CADILLAC trial randomized 2082 patients with acute myocardial infarction to stenting versus percutaneous transluminal coronary angioplasty, each with or without abciximab. Results: Earlier reperfusion(< 3 vs 3-6 vs >6 hours) was associated with lower 1-year mortality(2.6%vs 4.3%vs 4.8%, P=.046 for< 3 vs ≥3 hours), more frequent grade 2 to 3 myocardial blush(55%vs 53%vs 44%, P=.003), more frequent complete ST-segment resolution(64%vs 68%vs 47%, P=.006), and greater improvement in left ventricular function. Early reperfusion(< 3 vs 3-6 vs≥3 hours)was associated with lower mortality in high-risk patients(3.8%vs 6.9%vs 7.0%, P=.051 for< 3 vs ≥3 hours) but not in low-risk patients(1.4%vs 0.6%vs 1.0%, P=.63). Door-to-balloon times were independently correlated with mortality in patients presenting early after the onset of symptoms(≤2 hours, hazard ratio 1.24, P=.013) but not late(>2 hours, heart rate 0.88, P=.33). Conclusions: Early reperfusion results in superior clinical outcomes, enhanced microvascular reperfusion, and better recovery of left ventricular function. Incremental treatment delays impact mortality more in high-risk versus low-risk patients and more in patients presenting early versus late after the onset of symptoms. These data emphasize the importance of minimizing treatment delays and have implications regarding patient triage for primary percutaneous coronary intervention.

心电图ST段消退与急性心肌梗死首次经皮冠状动脉介入后早期和晚期结果的关系

ST-segment resolution(STR) is a surrogate end point in reperfusion trials of acute myocardial infarction, but there are few data regarding the optimum methods of measurement, clinical predictors, and correlation with late cardiac mortality. Consecutive patients(n=1,005) who had acute myocardial infarction and< 2 mm ST-segment elevation controlled with primary percutaneous coronary intervention(PCI) constituted our study group. Follow-up was obtained in 97%of patients at a median of 6.2 years. STR measured as maximum ST-segment elevation after PCI provided better discrimination of late cardiac mortality than did STR measured as percent resolution. Complete STR(< 1.0 mm ST-segment elevation after PCI) was achieved in only 42%of patients. Anterior infarction, Killip’s class 3 to 4, and Thrombolysis In Myocardial Infarction flow grades< 2 before PCI and< 3 after PCI were strong independent predictors of partial or poor STR. STR(complete [< 1.0 mm] vs partial [1.0 to 2.0 mm] vs poor [ >2.0 mm]) correlated with in-hospital mortality(4.0%vs 6.7%vs 11.6%, p=0.005), reinfarction(1.4%vs 3.4%vs 6.1%, p=0.01), and late cardiac mortality(17%vs 25%vs 44%, p< 0.0001). Correlation with late mortality was stronger for nonanterior than for anterior infarction. Poor STR was a strong independent predictor of late mortality(hazard ratio 1.63, 95%confidence interval 1.06 to 2.50, p= 0.028), even after adjusting for Thrombolysis In Myocardial Infarction flow. These data support the use of STR as a simple method to stratify patients by risk after primary PCI for acute myocardial infarction and support the use of STR as a surrogate end point in reperfusion trials of acute myocardial infarction.