Factors associated with failure of medical therapy in patients with unstable angina and non-Q wave myocardial infarction. A TIMI-IIIB database study.
Factors associated with failure of medical therapy in patients with unstable angina and non-Q wave myocardial infarction. A TIMI-IIIB database study.
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不稳定型心绞痛和非Q波心肌梗死患者药物治疗失败的相关因素。
DOI：
10.1053/euhj.1998.1480
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发表时间：
1999
期刊：
影响因子：
--
通讯作者：
Braunwald,E
中科院分区：
文献类型：
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作者：
Stone,PH;Thompson,B;Zaret,BL;Chaitman,B;Gibson,RS;Schweiger,MJ;Steingart,R;Kirshenbaum,J;Thompson,C;Fung,A;McCabe,CH;Knatterud,GL;Braunwald,E
目前对不稳定心绞痛和非q波心肌梗死患者的治疗通常包括强化药物治疗，血管造影和血运重建术有时仅限于那些治疗失败的患者。目的确定某些基线特征是否可以预测药物治疗失败的患者，因为这样的患者可以以具有成本效益的方式迅速转向更具侵入性的策略。方法研究队列包括心肌缺血溶栓（TIMI） IIIB研究中的733例患者，随机分为保守组。患者将接受卧床治疗、抗缺血药物、阿司匹林和肝素治疗，并进行风险分层试验，包括在出院前3天或出院后5天内进行心电图和铊闪烁成像的运动试验，并在随机分组后2-5天开始进行24小时动态心电图监测。比较药物治疗“失败”和“未失败”的患者的基线临床和心电图特征。失败是通过临床终点（随机分组后6周死亡、心肌梗死或自发性缺血）或强烈阳性的风险分层试验来定义的。对于每一个测试，一个有序的失败的结果被计算出来，包括死亡，心肌梗死，或在测试前发生的静息性缺血，一个明显异常的测试结果，和没有异常。临床终点发生在241例（33%）患者中，并且更有可能发生在就诊时年龄较大、心电图显示st段抑郁或正在接受肝素或阿司匹林治疗的患者中。独立预测发生临床事件或运动跑步机试验异常的特征包括：合格心电图st段下降、既往心绞痛史、早发冠心病家族史（即发病年龄<55岁）、既往使用肝素或阿司匹林以及年龄增长。通过结合每个结果的这些基线风险特征，发生临床事件的发生率从没有发生的8%到所有6例患者均出现的63%不等，发生明显异常风险分层试验的发生率从没有发生的8-21%到所有6例患者均出现的约90%不等。结论：与发生临床事件或明显异常危险分层试验相关的基线特征相似：静息性心绞痛发作伴st段抑制，尽管接受阿司匹林和肝素治疗，心绞痛史，年龄较大，有冠状动脉疾病家族史。具有这些特征的患者适合进行快速心导管插入术和考虑血运重建，而没有这些特征的患者可能适合单独进行医学治疗。
ContextCurrent management of patients with unstable angina and non-Q wave myocardial infarction generally consists of intensive medical therapy, with angiography and revascularization sometimes limited to those who fail such therapy.AimTo determine if certain baseline characteristics are predictive of patients who fail medical therapy, since such patients could then be expeditiously directed to a more invasive strategy in a cost-effective manner.MethodsThe study cohort consisted of the 733 patients in the Thrombolysis in Myocardial Ischemia (TIMI) IIIB study who were randomized to conservative strategy. Patients were to be treated with bedrest, anti-ischaemic medications, aspirin, and heparin, and were to undergo risk-stratifying tests, consisting of an exercise test with ECG and thallium scintigraphy, scheduled to be performed within 3 days prior to, or 5 days after, hospital discharge and 24h Holter monitoring scheduled to begin 2–5 days after randomization. Baseline clinical and ECG characteristics were compared between patients who ‘failed’ medical therapy and those who did not ‘fail’. Failure was defined using clinical end-points (death, myocardial infarction, or spontaneous ischaemia by 6 weeks after randomization) or a strongly positive risk-stratifying test. For each test an ordered failure profile of results was calculated and consisted of death, myocardial infarction, or rest ischaemia occurring prior to performance of the test, a markedly abnormal test result, and no abnormality.ResultsClinical end-points occurred in 241 (33%) patients and were more likely to occur in patients who at presentation were older, had ST-segment depression on the qualifying ECG, or were being treated with heparin or aspirin. Characteristics independently predictive of developing a clinical event or an abnormal exercise treadmill test included: ST-segment depression on the qualifying ECG, history of prior angina, family history of premature coronary disease (i.e. onset <55 years of age), prior use of heparin or aspirin, and increasing age. By combining these baseline risk characteristics for each outcome the incidence of developing a clinical event ranged from 8% if none was present to 63% if all six were present, and of developing a markedly abnormal risk stratifying test from 8–21% if none were present to approximately 90% if all six were present.ConclusionsBaseline characteristics associated with developing a clinical event or a markedly abnormal risk stratifying test were similar: rest anginal episode accompanied by ST-segment depression and occurring despite treatment with aspirin and heparin, a history of angina, older age, and family history of coronary disease. Patients with these characteristics are appropriate candidates for expeditious cardiac catheterization and consideration for revascularization, while patients without them may be suitable for medical management alone.