Značaj rane koronarografije i revaskularizacije u bolesnika sa akutnim infarktom miokarda bez ST-elevacije

Abstract

Uvod: Prethodne, kliničke, randomizovane studije su pokazale različite rezultate uticaja primene rane invazivne terapije kod bolesnika sa akutnim koronarnim sindromom bez elevacije ST-segmenta. Cilj studije je bio da se ispita uticaj hitne u odnosu na odloženu invazivnu terapiju kod bolesnika sa infarktom miokarda bez elevacije ST-segmenta (NSTEMI) na pojavu novog infarkta miokarda ili smrtnog ishoda posmatranih zajedno − primarni cilj; novog infarkta miokarda, smrtnog ishoda ili refraktarne ishemije posmatranih zajedno − sekundarni cilj tokom 30-dnevnog perioda praćenja. Metodologija: u odnosu na vreme primene invazivne terapije randomizovana su 323 NSTEMI bolesnika u grupe za hitnu (<2h nakon randomizacije, n=162) i odloženu invazivnu terapiju (<72h nakon randomizacije, n=161). Rezultati: mediana vremena od randomizacije do angiografije je u grupi za hitnu invazivnu terapiju iznosila 1,4h, a u grupi za odloženu 61,0h (p< 0.001). Upoređivane grupe su bile slične u pogledu osnovnih, kliničkih i angiografskih karakteristika. Nakon 30 dana, procenat smrtnog ishoda ili novog infarkta miokarda posmatranih zajedno je bio značajno niži kod bolesnika u grupi za hitnu, u odnosu na odloženu invazivnu terapiju (4,3% vs 13%, p=0.008). Postignuta razlika je rezultat značajno manjeg procenta novog infarkta miokarda u prekateterizacionom periodu (0 smrt + 0 IM u grupi za hitnu vs 1 smrt+10 IM u grupi za odloženu invazivnu terapiju). Takođe, hitna invazivna terapija je bila povezana sa nižom incidencom refraktarne ishemije. U pogledu pojave velikog krvarenja hitna invazivna terapija je bila sigurna kao i odložena (0,6% vs 0,6%), ali je bila povezana sa značajno većim procentom minimalnog krvarenja koje je uglavnom vezano za mesto punkcije (8,0% vs 3,7%, hitna vs odložena). Zaključak: hitna primena invazivne terapije kod bolesnika sa NSTEMI povezana je sa nižim procentom smrtnog ishoda ili novog infarkta miokarda posmatranih zajedno, u poređenju sa odloženom invazivnom terapijom, usled smanjena rizika od novog novog infarkta u prekateterizacionom periodu.

Background: Previous, clinical, randomized studies provided heterogeneous results on the effects of earlier invasive intervention in patients with acute coronary syndrome without ST-segment elevation. The aim of this study was to assess the impact of immediate versus delayed invasive intervention in patients with non-ST-segment myocardial infarction (NSTEMI) on composite of new myocardial infarction or death – primary endpoint, and composite of new myocardial infarction, death or refractory ishaemia – secondary endpoint, during 30 day follow-up. Methods: According to the time of performing invasive therapy were randomized 323 NSTEMI patients into immediate (<2h after randomization, n=162) and delayed-intervention group (<72h after randomization, n=161). Results: Median time from randomization to angiography in the immediate group was 1,4h and 61,0h in the delayed group (p < 0.001).The immediate and delyed intervention group were well matched with respect to major baseline, clinical and angiography characteristic. At 30 days, the rate of the primary endpoint was lower in patients undergoing immediate versus delayed intervention (4,3% vs 13%, respectively; p=0.008). The observed results were mainly attributable to the occurrence of new MI in the pre-catheterization period (0 deaths + 0 MIs in the immediate-intervention vs 1 death + 10 MIs in the delayed-intervention group). Also, immediate invasive strategy was associate with low incidence of recurrent ischaemia. Immediate invasive strategy was safe as delayed in terms of major bleeding (0,6% vs 0,6%), but was associated with significantly higher non-major bleeding which were mostly puncture-related (8,0 % vs 3,7%). Conclusion: Immediate invasive strategy in NSTEMI patients is associated with lower rates of death or new MI compared the delayed invasive strategy, mainly due to minimization of the risk of new MI in the pre-catheterization time.