应用纤溶治疗的ST段抬高的急性心肌梗死患者中分别采用TIMI危险评分和TIMI血流分级方法进行危险因素分层

In the setting of ST-segment elevation myocardial infarction (STEMI), the Thrombolysis In Myocardial Infarction (TIMI) risk score(TRS) and indexes of epicardial and myocardial perfusion are associated with mortality. The association between TRS at presentation and angiographic indexes of epicardial and myocardial perfusion after reperfusion therapy has not been investigated. We hypothesized that TRS, TIMI flow grade(TFG), and TIMI myocardial perfusion grade(TMPG) would provide independent prognostic information and that angiographic indexes of poor flow and perfusion would be associated with a higher TRS. TRS and angiographic data were evaluated in 3,801 patients from the TIMI 4, 10A, 10B, 14, 20, 23, and 24 trials.Within each TRS stratum(TRS 0 to 2, 3 to 4, ≥5), 30-day mortality increased stepwise among patientswith impaired TFG at 60 minutes after fibrinolytic administration. In a multivariate model adjusting for the TRS strata, impaired TMPG(0/1) was independently associated with highermortality(odds ratio 2.28, p=0.018). In a multivariate model adjusting for the TFG and infarct location, the likelihood of impaired TMPG (0/1) was greater among intermediate-risk(TRS 3 to 4) and high-risk(TRS≥5) patients than among low-risk(TRS 0 to 2) patients(odds ratio 1.43, p=0.019 and 1.50, p=0.055, respectively). Thus, impaired epicardial flowand myocardial perfusion are independently associated with increased 30-day mortality among patients identified by TRS as high risk, although there is no synergism between either TFG or TMPG and TRS. High TRS at presentation is associated with abnormal myocardial perfusion, even after adjusting for possible confounders.

比较应用裸金属支架与药物洗脱支架行经皮冠状动脉介入治疗非ST段抬高型急性冠状动脉综合征对生物标记物水平的影响

Drug-eluting stents(DESs) deliver biphasic(early and late)-elution of anti-inflammatory compounds. We therefore hypothesized that DESs would be associated with early reductions in inflammatory biomarker release after percutaneous coronary intervention(PCI). A total of 741 patients with non-ST-elevation acute coronary syndrome underwent PCI in the Randomized Trial to Evaluate the Relative PROTECTion against Post-PCI Microvascular Dysfunction and Post-PCI Ischemia among Anti-Platelet and Anti-Thrombotic Agents(PROTECT) Thrombolysis In Myocardial Infarction 30 study of eptifibatide and reduced-dose antithrombin compared with bivalirudin. Serial biomarkers C-reactive protein, troponin, creatine kinase-MB, soluble CD40 ligand, interleukin-6, prothrombin fragment F1.2, and RANTES(regulated on activation, normal T-cell expressed and secreted) were assessed through 24 hours after PCI. DES use was at the investigator’s discretion. Patients treated with DESs(n=665) versus bare metal stents(n=139) were more likely to have patent arteries before PCI(92.0%vs 86.6%, p=0.04), Thrombolysis In Myocardial Infarction myocardial perfusion grade 3(57.9%vs 47.7%, p=0.033), and the left anterior descending artery as the culprit artery(38.5%vs 18.3%, p< 0.001). The increase in C-reactive protein and troponin was lower among patients undergoing DES implantation(median 2.1 vs 3.5 mg/L for C-reactive protein, median 0.11 vs 0.41 ng/ml for troponin), even after adjustment for randomized treatment, clopidogrel before treatment, diabetes mellitus status, epicardial patency, left anterior descending artery location, and myocardial perfusion(p=0.036 and p=0.039, respectively). Interleukin-6 was lower with DESs on univariate analysis but not multivariate analysis. Creatine kinase-MB, soluble sCD40 ligand, prothrombin fragment F1.2, and RANTES did not differ by DES use. In conclusion, patients undergoing DES implantation achieved more reductions in periprocedural markers of inflammation and necrosis than patients receiving bare metal stents among those with non-ST-elevation acute coronary syndrome.

“犯罪”损伤处钙与ST段抬高型心肌梗死并接受纤维蛋白溶解治疗患者的血管造影及临床预后之间的联系

Coronary artery calcium has been associated with a greater extent of angiographically significant coronary artery stenoses, but the angiographic and clinical outcomes associated with culprit lesion calcium(CLC) have not been fully evaluated, particularly in the stetting of ST-elevation myocardial infarction. We hypothesized that CLC would be associated with adverse angiographic and clinical outcomes in patients who had ST-elevation myocardial infarction. Data were evaluated in 3,292 patients from 6 trials of fibrinolytic therapy for ST-elevation myocardial infarction; 243 culprit lesions(7.4%) were calcified. CLC was associated with advanced age, history of hypertension, previous coronary artery disease, greater extent of disease, angio graphically evident residual thrombus, smaller minimum luminal diameter, and larger percent residual stenosis after fibrinolytic therapy. CLC was associated with lower rates of arterial patency after fibrinolytic therapy(63.3%vs 81.3%p< 0.001), lower rates of Thrombolysis In Myocardial Infarction grade 3 flow(41.5%vs 57.2%, p< 0.001), and higher(slower) Thrombolysis In Myocardial Infarction frame counts(52 vs 36 frames, p< 0.0001, multivariate p=0.02). CLC was also associated with increased 30-day mortality rates(6.2%vs 3.4%, p=0.028) and 30-day rates of death, myocardial infarction, or congestive heart failure(16.5%vs 8.9%, p< 0.001) and independently associated with 30-day rates of death, myocardial infarction, or congestive heart failure(odds ratio 1.6, p=0.016) after multivariate adjustment for baseline clinical and lesion characteristics, epicardial flow, and performance of rescue/ adjunctive percutaneous coronary intervention. In a model restricted to patients who had successful restoration of epicardial patency after fibrinolytic therapy, CLC was independently associated with 30-day mortality(odds ratio 2.2, p=0.045). CLC is independently associated with indexes of poorer epicardial flow and a higher incidence of adverse clinical outcomes after fibrinolytic administration in patients who have ST-elevation myocardial infarction.