Early revascularization in acute myocardial infarction complicated by cardiogenic shock
Early revascularization in acute myocardial infarction complicated by cardiogenic shock
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DOI：
10.1056/nejm199908263410901
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发表时间：
1999-08-26
影响因子：
158.5
通讯作者：
LeJemtel, TH
中科院分区：
文献类型：
--
作者：
Hochman, JS;Sleeper, LA;LeJemtel, TH
研究背景心源性休克是急性心肌梗死住院患者的主要死亡原因。我们进行了一项随机试验，以评估早期血运重建的患者与心源性shock.Methods休克患者由于左心室衰竭并发心肌梗死被随机分配到紧急血运重建（152例）或初始医疗稳定（150例）。血运重建通过冠状动脉旁路移植术或血管成形术完成。两组中86%的患者进行了主动脉内球囊反搏。主要终点是30天时所有原因导致的死亡率。6个月的生存率是次要终点。结果患者的平均（+/-SD）年龄为66+/-10岁，32%为女性，55%从其他医院转来。至休克发作的中位时间为梗死后5.6小时，大多数梗死位于前部。97%的患者接受了早期冠状动脉造影，87%的患者接受了血运重建;只有2.7%的患者在没有临床指征的情况下接受了药物治疗。血运重建组和药物治疗组之间30天的总死亡率没有显著差异（分别为46.7%和56.0%;差异为-9.3%;差异的95%置信区间为-20.5%至1.9%; P = 0.11）。血运重建组的6个月死亡率低于药物治疗组（50.3% vs. 63.1%，P=0.027）。然而，六个月后，有一个显着的生存效益。对急性心肌梗死合并心源性休克的患者应考虑早期血运重建。（《新英格兰医学杂志》1999年;341：625-34。）(C)1999年，马萨诸塞州医学会。
Background The leading cause of death in patients hospitalized for acute myocardial infarction is cardiogenic shock. We conducted a randomized trial to evaluate early revascularization in patients with cardiogenic shock.Methods Patients with shock due to left ventricular failure complicating myocardial infarction were randomly assigned to emergency revascularization (152 patients) or initial medical stabilization (150 patients). Revascularization was accomplished by either coronary-artery bypass grafting or angioplasty. Intraaortic balloon counterpulsation was performed in 86 percent of the patients in both groups. The primary end point was mortality from all causes at 30 days. Six-month survival was a secondary end point.Results The mean (+/-SD) age of the patients was 66+/-10 years, 32 percent were women, and 55 percent had been transferred from other hospitals. The median time to the onset of shock was 5.6 hours after infarction, and most infarcts were anterior in location. Ninety-seven percent of the patients assigned to revascularization underwent early coronary angiography, and 87 percent underwent revascularization; only 2.7 percent of the patients assigned to medical therapy crossed over to early revascularization without clinical indication. Overall mortality at 30 days did not differ significantly between the revascularization and medical-therapy groups (46.7 percent and 56.0 percent, respectively; difference, -9.3 percent; 95 percent confidence interval for the difference, -20.5 to 1.9 percent; P = 0.11). Six-month mortality was lower in the revascularization group than in the medical-therapy group (50.3 percent vs. 63.1 percent, P=0.027).Conclusions In patients with cardiogenic shock, emergency revascularization did not significantly reduce overall mortality at 30 days. However, after six months there was a significant survival benefit. Early revascularization should be strongly considered for patients with acute myocardial infarction complicated by cardiogenic shock. (N Engl J Med 1999;341:625-34.) (C) 1999, Massachusetts Medical Society.