Rescue angioplasty after failed thrombolytic therapy for acute myocardial infarction
Rescue angioplasty after failed thrombolytic therapy for acute myocardial infarction
复制标题
DOI：
10.1056/nejmoa050849
复制
发表时间：
2005-12-29
影响因子：
158.5
通讯作者：
Wilcox, R
中科院分区：
文献类型：
--
作者：
Gershlick, AH;Stephens-Lloyd, A;Wilcox, R
背景急性心肌梗死溶栓治疗后再灌注失败的患者的适当治疗仍不清楚。有几个数据比较紧急经皮冠状动脉介入治疗（抢救PCI）与保守治疗，在这样的患者，没有比较抢救PCI与反复thrombolysis.MethodsWe进行了一项多中心试验，在英国涉及427例ST段抬高心肌梗死溶栓治疗后90分钟内未能发生再灌注（ST段分辨率低于50%）。患者被随机分配至重复溶栓（142例患者）、保守治疗（141例患者）或补救PCI（144例患者）。主要终点是一个复合死亡，再梗死，中风，或严重的心脏衰竭在6个months.ResultsThe事件的无事件生存率与补救PCI治疗的患者为84.6%，相比之下，70.1%的保守治疗和68.7%的反复溶栓治疗（总体P=0.004）。重复溶栓治疗与保守治疗的主要终点发生率的校正风险比为1.09（95%置信区间，0.71至1.67; P=0.69），相比之下，调整后的风险比为0.43（95%置信区间，0.26 - 0.72; P=0.001），补救PCI与重复溶栓相比，0.47（95%置信区间，0.28 - 0.79; P=0.004）。所有原因的死亡率无显著差异。非致命性出血（主要发生在鞘管插入部位）在补救性PCI中更常见。6个月时，86.2%的补救PCI组免于血运重建，与保守治疗组的77.6%和重复溶栓组的74.4%（总体P=0.05）相比，补救PCI溶栓治疗失败后的无事件生存率显著高于重复溶栓或保守治疗。溶栓治疗后再灌注失败的患者应考虑补救PCI。
BackgroundThe appropriate treatment for patients in whom reperfusion fails to occur after thrombolytic therapy for acute myocardial infarction remains unclear. There are few data comparing emergency percutaneous coronary intervention (rescue PCI) with conservative care in such patients, and none comparing rescue PCI with repeated thrombolysis.MethodsWe conducted a multicenter trial in the United Kingdom involving 427 patients with ST-segment elevation myocardial infarction in whom reperfusion failed to occur (less than 50 percent ST-segment resolution) within 90 minutes after thrombolytic treatment. The patients were randomly assigned to repeated thrombolysis (142 patients), conservative treatment (141 patients), or rescue PCI (144 patients). The primary end point was a composite of death, reinfarction, stroke, or severe heart failure within six months.ResultsThe rate of event-free survival among patients treated with rescue PCI was 84.6 percent, as compared with 70.1 percent among those receiving conservative therapy and 68.7 percent among those undergoing repeated thrombolysis (overall P=0.004). The adjusted hazard ratio for the occurrence of the primary end point for repeated thrombolysis versus conservative therapy was 1.09 (95 percent confidence interval, 0.71 to 1.67; P=0.69), as compared with adjusted hazard ratios of 0.43 (95 percent confidence interval, 0.26 to 0.72; P=0.001) for rescue PCI versus repeated thrombolysis and 0.47 (95 percent confidence interval, 0.28 to 0.79; P=0.004) for rescue PCI versus conservative therapy. There were no significant differences in mortality from all causes. Nonfatal bleeding, mostly at the sheath-insertion site, was more common with rescue PCI. At six months, 86.2 percent of the rescue-PCI group were free from revascularization, as compared with 77.6 percent of the conservative-therapy group and 74.4 percent of the repeated-thrombolysis group (overall P=0.05).ConclusionsEvent-free survival after failed thrombolytic therapy was significantly higher with rescue PCI than with repeated thrombolysis or conservative treatment. Rescue PCI should be considered for patients in whom reperfusion fails to occur after thrombolytic therapy.