Comparison of early invasive and conservative strategies in patients with unstable coronary syndromes treated with the glycoprotein IIb/IIIa inhibitor tirofiban.
Comparison of early invasive and conservative strategies in patients with unstable coronary syndromes treated with the glycoprotein IIb/IIIa inhibitor tirofiban.
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DOI：
10.1056/nejm200106213442501
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发表时间：
2001-06-21
影响因子：
158.5
通讯作者：
Braunwald, E
中科院分区：
文献类型：
--
作者：
Cannon, CP;Weintraub, WS;Braunwald, E
背景资料：对于不稳定型心绞痛和无ST段抬高的心肌梗死，常规的早期侵入性治疗策略是否上级保守治疗策略仍有争议。方法：我们纳入了2220例不稳定型心绞痛和心肌梗死患者，这些患者无ST段抬高，心电图显示ST段或T波改变，心脏标志物水平升高，冠状动脉疾病史或所有三项发现。所有患者均接受阿司匹林、肝素和糖蛋白IIb/IIIa抑制剂替罗非班治疗。他们被随机分配到早期侵入性策略，其中包括4至48小时内的常规导管插入术和适当的血运重建，或更保守的（选择性侵入性）策略，其中导管插入术仅在患者有复发性缺血或异常负荷试验的客观证据时进行。主要终点是6个月时死亡、非致命性心肌梗死和因急性冠脉综合征再住院的复合终点。结果：6个月时，早期侵入性策略的主要终点发生率为15.9%，保守策略为19.4（比值比，0.78; 95%置信区间，0.62至0.97; P=0.025）。6个月时死亡或非致命性心肌梗死的发生率也同样降低（7.3%对9.5%;比值比，0.74; 95%置信区间，0.54 - 1.00; P
Background: There is continued debate as to whether a routine, early invasive strategy is superior to a conservative strategy for the management of unstable angina and myocardial infarction without ST-segment elevation.Methods: We enrolled 2220 patients with unstable angina and myocardial infarction without ST-segment elevation who had electrocardiographic evidence of changes in the ST segment or T wave, elevated levels of cardiac markers, a history of coronary artery disease, or all three findings. All patients were treated with aspirin, heparin, and the glycoprotein IIb/IIIa inhibitor tirofiban. They were randomly assigned to an early invasive strategy, which included routine catheterization within 4 to 48 hours and revascularization as appropriate, or to a more conservative (selectively invasive) strategy, in which catheterization was performed only if the patient had objective evidence of recurrent ischemia or an abnormal stress test. The primary end point was a composite of death, nonfatal myocardial infarction, and rehospitalization for an acute coronary syndrome at six months.Results: At six months, the rate of the primary end point was 15.9 percent with use of the early invasive strategy and 19.4 percent with use of the conservative strategy (odds ratio, 0.78; 95 percent confidence interval, 0.62 to 0.97; P=0.025). The rate of death or nonfatal myocardial infarction at six months was similarly reduced (7.3 percent vs. 9.5 percent; odds ratio, 0.74; 95 percent confidence interval, 0.54 to 1.00; P