Consequences of reocclusion after successful reperfusion therapy in acute myocardial infarction. TAMI Study Group.
Consequences of reocclusion after successful reperfusion therapy in acute myocardial infarction. TAMI Study Group.
复制标题
急性心肌梗死成功再灌注治疗后再闭塞的后果。
DOI：
10.1161/01.cir.82.3.781
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发表时间：
1990
期刊：
影响因子：
37.8
通讯作者：
Stack,R
中科院分区：
文献类型：
--
作者：
Ohman,EM;Califf,RM;Topol,EJ;Candela,R;Abbottsmith,C;Ellis,S;Sigmon,KN;Kereiakes,D;George,B;Stack,R
为了确定再灌注治疗后梗塞相关动脉再闭塞的临床后果，我们评估了 810 名急性心肌梗塞患者。患者被纳入四项具有相似进入标准的连续研究，其中在溶栓治疗开始后 90 分钟通过冠状动脉造影评估梗塞相关动脉的通畅性。 733 名患者急性再灌注成功。溶栓治疗包括 517 例患者使用组织型纤溶酶原激活剂 (t-PA)，87 例患者使用尿激酶，129 例患者使用 t-PA 和尿激酶联合治疗。所有患者在恢复期均接受阿司匹林、静脉注射肝素和硝酸甘油以及地尔硫卓治疗。 88% 的患者在症状出现后平均 7 天进行了重复冠状动脉造影。 91 名患者 (12.4%) 发生梗塞相关动脉再闭塞，其中 58% 有症状。溶栓治疗后 90 分钟的血管造影特征与冠状动脉持续通畅相比，与再闭塞相关的特征是右冠状动脉梗塞相关动脉（分别为 65% 和 44%），以及进一步干预前心肌梗塞溶栓 (TIMI) 流量为 0 或 1（分别为 21% 和 10%）。 90 分钟时，梗塞相关动脉的中位（四分位值）狭窄程度在各组之间相似：再闭塞组为 99%（值，90/100%），而开放组为 95%（值，80/99%）。随访时，与持续通畅的患者相比，再闭塞患者的左心室射血分数相似。然而，随访时再闭塞的患者梗塞区功能较差，分别为 -2.7（值，-3.2/-1.8）与 -2.4（SD/弦）（值，-3.1/-1.3）（p = 0.016）。与保持通畅相比，梗塞相关动脉的再闭塞损害了整体功能和梗塞区功能的恢复；与 1 相比，中位 Delta 射血分数为 -2 (p = 0.006)，中位 Delta 梗塞区室壁运动为 -0.10，与 0.34 SD/chord (p = 0.011) 相比。此外，再闭塞患者的住院病程更复杂，院内死亡率更高（分别为 11.0% 和 4.5%；p = 0.01）。我们的结论是，成功再灌注后梗塞相关动脉的再闭塞与显着的发病率和死亡率相关。再闭塞也不利于整体和梗死区区域左心室功能的功能恢复。因此，需要制定梗塞后的新策略来防止梗塞相关动脉的再闭塞。
To determine the clinical consequences of reocclusion of an infarct-related artery after reperfusion therapy, we evaluated 810 patients with acute myocardial infarction. Patients were admitted into four sequential studies with similar entry criteria in which patency of the infarct-related artery was assessed by coronary arteriography 90 minutes after onset of thrombolytic therapy. Successful reperfusion was established acutely in 733 patients. Thrombolytic therapy included tissue-type plasminogen activator (t-PA) in 517, urokinase in 87, and a combination of t-PA and urokinase in 129 patients. All patients received aspirin, intravenous heparin and nitroglycerin, and diltiazem during the recovery phase. A repeat coronary arteriogram was performed in 88% of patients at a median of 7 days after the onset of symptoms. Reocclusion of the infarct-related artery occurred in 91 patients (12.4%), and 58% of these were symptomatic. Angiographic characteristics at 90 minutes after thrombolytic therapy that were associated with reocclusion compared with sustained coronary artery patency were right coronary infarct-related artery (65% versus 44%, respectively) and Thrombolysis in Myocardial Infarction (TIMI) flow 0 or 1 (21% versus 10%, respectively) before further intervention. Median (interquartile value) degree of stenosis in the infarct-related artery at 90 minutes was similar between groups: 99% for reoccluded (value, 90/100%) compared with 95% for patent (value, 80/99%). Patients with reocclusion had similar left ventricular ejection fractions compared with patients with sustained patency at follow-up. However, patients with reocclusion at follow-up had worse infarct-zone function at -2.7 (value, -3.2/-1.8) versus -2.4 (SD/chord) (value, -3.1/-1.3) (p = 0.016). The recovery of both global and infarct-zone function was impaired by reocclusion of the infarct-related artery compared with maintained patency; median delta ejection fraction was -2 compared with 1 (p = 0.006) and median delta infarct-zone wall motion was -0.10 compared with 0.34 SD/chord (p = 0.011), respectively. In addition, patients with reocclusion had more complicated hospital courses and higher in-hospital mortality rates (11.0% versus 4.5%, respectively; p = 0.01). We conclude that reocclusion of the infarct-related artery after successful reperfusion is associated with substantial morbidity and mortality rates. Reocclusion is also detrimental to the functional recovery of both global and infarct-zone regional left ventricular function. Thus, new strategies in the postinfarction period need to be developed to prevent reocclusion of the infarct-related artery.