心肌梗塞和脑梗塞溶栓治疗的证据比较
摘要：
关键词：
心肌梗塞和脑梗塞是对人们健康危害极大的一种疾病，死亡率高。它们都是由于血管被血栓阻塞引起的心、脑细胞供血不足所致的缺血性坏死。溶栓药物可以通过溶解血栓、恢复血供来减少心、脑细胞的损伤。溶栓治疗在心肌梗塞已经成为经典的治疗方法之一，大量的随机对照试验（randomized control trial, RCT）已证实，溶栓治疗能够降低死亡率。但心肌梗塞患者是否溶栓治疗是最佳选择？PTCA相对于溶栓治疗优势何在？由于相同的病理生理机制，脑梗塞患者溶栓治疗情况如何？是最佳选择吗？等等，都是临床医生关心的问题。本文通过复习近年来所发表的，能提供临床证据的RCT和系统评价，对上述问题进行阐述说明。
一．检索资源和内容
我们检索了最新Cochrane图书馆（2001年第2期）、MEDLINE（1980－2001.6），收集有关心肌梗塞和脑梗塞溶栓治疗的系统评价和Meta分析以及大型的RCT。
二．研究结果
1．脑梗塞溶栓治疗已完成2个系统评价（systematic review，SR）。一个SR是评价溶栓治疗对脑梗塞的有效性和安全性，共纳入17个RCT，5216名患者，以死亡率、致残率为试验终点，15个RCT为双盲设计，溶栓药物包括尿激酶、链激酶、重组组织纤维蛋白溶酶原激活物（ recombinant tissue plasminogen activator，tPA）或重组尿激酶原（ recombinant pro-urokinase）， 2个试验采取动脉内给药，余均是静脉途径用药。一半的试验资料是静脉用tPA。
trials testing intravenous tissue Plasminogen Activator. Thrombolytic therapy significantly increased the odds of death within the first ten days (odds ratio [OR] 1.85, 95% confidence interval [CI] 1.48 to 2.32). The main cause of the increase in deaths was fatal intracranial haemorrhage following thrombolysis (OR 4.15, 95% CI 2.96 to 5.84). Symptomatic intracranial haemorrhage is also increased following thrombolysis (OR 3.53, 95% CI 2.79 to 4.45). Thrombolytic therapy also increased the odds of death at the end of follow-up (OR 1.31, 95% CI
1.13 to 1.52). Despite this, thrombolytic therapy, administered up to six hours after ischaemic stroke, significantly reduced the proportion of patients who were dead or dependent (modified Rankin 3 to 6) at the end of follow-up (OR 0.83, 95% CI 0.73 to 0.94). For patients treated within three hours of stroke, thrombolytic therapy appeared more effective in reducing death or dependency (OR 0.58, 95% CI 0.46 to 0.74) with less adverse effect on death (OR 1.11, 95% CI 0.84 to 1.47). There was heterogeneity between the trials that could have been due to : thrombolytic drug used, variation in the concomitant use of aspirin and heparin, severity of the stroke, and time to treatment. Trials testing intravenous recombinant tissue Plasminogen Activator suggest that it may be associated with slightly less hazard and more benefit when given up to six hours after stroke - death within the first ten days OR 1.24, 95% CI 0.85 to 1.81, death at the end of follow-up OR 1.16, 95% CI 0.94 to 1.44, dead or
dependent at the end of follow-up OR 0.79, 95% CI 0.68 to 0.92. One trial that tested thrombolysis plus aspirin showed an increase in deaths of patients given both drugs in combination compared with thrombolysis alone. Reviewers' conclusions: Thrombolytic therapy increases deaths within the first seven to ten days, and deaths at final follow-up. Thrombolytic therapy also significantly increases symptomatic and fatal intracranial haemorrhage. These risks
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