就诊时血小板计数与ST段抬高型心肌梗死临床预后之间的相关性(来自TIMI试验)

Platelet activation and aggregation play pivotal roles in the thrombotic process of acute coronary syndromes. However, data regarding platelet count and its association with clinical outcomes in the setting of ST-elevation myocardial infarction(STEMI) are limited. We hypothesized that higher platelet counts on presentation would be associated with poorer clinical outcomes. Data from 10,793 patients with STEMI in the Thrombolysis In Myocardial Infarction(TIMI) trials database were analyzed. Mean platelet count on presentation was 254.8×103/μl. Higher platelet counts were associated with higher rates of adverse clinical outcomes at 30 days. In a multivariable analysis that adjusted for confounders of platelet counts(age, gender, weight, diabetes, and smoking), higher platelet counts remained associated with an increased risk of the combined end point of death, reinfarction, and congestive heart failure. With a reference group of platelet counts< 200×103/μl, the multivariable odds ratios were 1.22(95%confidence interval 1.05 to 1.42, p=0.009) for platelet counts of 201 to 300×103/μl, 1.37(95%confidence interval 1.11 to 1.68, p=0.002) for counts of 301 to 400×103/μl, and 1.71(95%confidence interval 1.16 to 2.51, p=0.005) for counts >400×103/μl. Further, a greater decrease in follow-up platelet counts(compared with baseline values) was independently associated with an increased risk of reinfarction at 30 days(odds ratio 1.44 for every decrease of 100×103/μl unit of platelets, 95%confidence interval 1.13 to 1.82, p=0.03). In conclusion, in STEMI, a higher platelet count on presentation was independently associated with adverse clinical outcomes, whereas a greater subsequent platelet count decrease was associated with an increased risk of reinfarction.

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.

ST段抬高型心肌梗死患者行直接经皮冠状动脉介入术前依替巴肽的急诊早期使用:TITAN(急性心肌梗死患者中至应用依替巴肽治疗时间)-TIMI34试验的结果

背景:ST段抬高型心肌梗死(STEMI)患者行直接经皮冠状动脉介入(PCI)术前心外膜血流的早期恢复常伴有较好的临床预后。方法:设想,与在心脏导管室(CCL)行诊断性血管造影后使用血小板糖蛋白IIb/IIIa受体拮抗剂依替巴肽相比较,行PCI术前在急诊科(ED)早期使用依替巴肽可获得更好的心外膜血流和心肌灌注。343例STEMI患者被随机分为两组,分别于ED早期(n=180)或CCL(n=163)应用依替巴肽。

接受经皮冠状动脉介入和依替巴肽治疗的中高危患者中出血事件的相关因素:来自PROTECT-TIMI-30试验的观察

Objectives: We aimed to identify correlates of Thrombolysis In Mycocardial Infarction(TIMI) major/minor bleeding among eptifibatide-treated patients undergoing percutaneous coronary intervention(PCI). Background: Evaluation of bleeding predictors among patients treated with glycoprotein IIb/IIIa receptor inhibition might aid in the identification of targets to reduce bleeding risk. Methods: Data were analyzed from 567 moderate-to high-risk PCI patients with non-ST-segment elevation acute coronary syndrome(NSTEACS) treated with eptifibatide/reduced-dose unfractionated heparin or eptifibatide/ reduced-dose enoxaparin enrolled 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-Thrombolysis In Myocardial Infarction-30(PROTECT-TIMI-30). Results: The incidence of significant bleeding was 3.2%with a median time to event of 7.0 h after the first eptifibatide bolus. Increased age was the only independent correlate of bleeding events. Among patients with reduced creatinine clearance(CrCl), lack of adjustment of the maintenance infusion for CrCl ≤50 ml/min occurred frequently(15 of 33 patients, or 45%) and was associated with a high rate of bleeding(20%). The association of CrCl with bleeding appeared to be largely mediated by the incorporation of age in the estimation of CrCl. Patient gender, Cr, weight, and the peak activated clotting time were not associated with bleeding. Conclusions: Among NSTEACS PCI patients treated with eptifibatide, increased age was a significant correlate of bleeding events and appeared to explain the association between low CrCl and bleeding. The more widespread use of CrCl or other estimates of renal function over Cr may lead to more appropriate dose adjustments of eptifibatide.

“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.