藥物治療冠脈內支架置入術后無再流的系統評價_《中國循證醫學雜志》

作者：

張小衛 ^1,2 , 楊克虎 ¹ , 馬彬 ¹ ,  白鋒 ²

1. 蘭州大學循證醫學中心，蘭州大學基礎醫學院（蘭州?730000）；2. 蘭州大學第二醫院（蘭州?730000）;

關鍵詞：

無再流冠狀動脈介入治療藥物治療隨機對照試驗系統評價

DOI：

10.7507/1672-2531.20090153

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目的　系統評價藥物（腺苷、尿激酶、山莨菪堿等）冠狀動脈內注射治療冠脈內支架置入術后慢血流/無再流的臨床療效與安全性。
方法　計算機檢索Cochrane圖書館Cochrane對照試驗注冊數據庫（2009年第2期）、PubMed、MEDLINE、EMbase、CBM、CNKI、VIP，萬方數據資源（截至2009年4月）。由2名評價者獨立評價并交叉核對納入研究的質量，對同質研究采用RevMan 5.0軟件進行Meta分析。
結果　共納入8個RCT，包括593例患者。Meta分析結果顯示，尿激酶、腺苷和山莨菪堿均可明顯改善心肌梗死溶栓治療血流；山莨菪堿還可提高冠脈內血壓。就不良反應而言，尿激酶能明顯降低住院期間惡性室性心律失常及非致死性心力衰竭的發生率，但不能改變患者住院期間的病死率、不穩定型心絞痛、再發心肌梗死和缺血性靶血管重建的發生率。
結論　本系統評價結果顯示，山莨菪堿、尿激酶、烏拉地爾、腺苷對無再流的患者療效較好，可明顯提高心肌梗死溶栓治療血流，改善心肌灌注，尿激酶還能明顯降低住院期間部份心血管主要不良事件的發生率，值得臨床推廣應用。

引用本文： 張小衛,楊克虎,馬彬,白鋒. 藥物治療冠脈內支架置入術后無再流的系統評價. 中國循證醫學雜志, 2009, 09(8): 866-872. doi: 10.7507/1672-2531.20090153 復制

1.	Zijlstra F, de Boer MJ, Hoorntje JC, et al. A comparison of immediate coronary angioplasty with intravenous streptokinase in acute myocardial infarction. N Engl J Med, 1993, 328: 680-684.
2.	Weaver WD, Simes RJ, Betriu A, et al. Comparison of primary coronary angioplasty and intravenous thrombolytic therapy for acute myocardial infarction: a quantitative review. JAMA, 1997, 278: 2093-2098.
3.	Keeley EC, Boura JA, Grines CL. Primary angioplasty versus intravenous thrombolytic therapy for acute myocardial infarction: a quantitative review of 23 randomised trials. Lancet, 2003, 361: 13-20.
4.	Abbo KM, Dooris M, Glazier S, et al. Features and outcome of no-reflow after percutaneous coronary intervention. Am J Cardiol, 1995, 75: 778-782.
5.	Resnic FS, Wainstein M, Lee MK, et al. No-reflow is an independent predictor of death and myocardial infarction after percutaneous coronary intervention. Am Heart J, 2003, 145: 42-46.
6.	Piana RN, Paik GY, Moscucci M, et al. Incidence and treatment of ’no-reflow’ after percutaneous coronary intervention. Circulation, 1994, 89: 2514-2518.
7.	Mizote I, Ueda Y, Ohtani T, et al. Distal protection improved reperfusion and reduced left ventricular dysfunction in patients with acute myocardial infarction who had angioscopically defined ruptured plaque. Circulation, 2005, 1001-1007.
8.	Laude K, Beauchamp P, Thuillez C, et al. Endothelial protective effects of preconditioning. Cardiovasc Res, 2002, 55: 466-473.
9.	Kemper AJ, O’Boyle JE, Cohen CA, et al. Hydrogen peroxide contrast echocardiography: quantification in vivo of myocardial risk area during coronary occlusion and of the necrotic area remaining after myocardial reperfusion. Circulation, 1984, 70: 309-317.
10.	Topol EJ, Yadav JS. Recognition of the importance of embolization in atherosclerotic vascular disease. Circulation, 2000, 101: 570-580.
11.	Eeckhout E, Kern MJ. The coronary no-reflow phenomenon: a review of mechanisms and therapies. Eur Heart J, 2001, 22: 729-739.
12.	Herrmann J. Peri-procedural myocardial injury: 2005 update. Eur Heart J, 2005, 26: 2493-2519.
13.	Assali AR, Sdringola S, Ghani M, et al. Intracoronary adenosine administered during percutaneous intervention in acute myocardial infarction and reduction in the incidence of "no reflow" phenomenon. Catheter Cardiovasc Interv, 2000, 51: 27-31; discussion 32.
14.	Marzilli M, Orsini E, Marraccini P, et al. Beneficial effects of intracoronary adenosine as an adjunct to primary angioplasty in acute myocardial infarction. Circulation, 2000, 101: 2154-2159.
15.	Micari A, Belcik TA, Balcells EA, et al. Improvement in microvascular reflow and reduction of infarct size with adenosine in patients undergoing primary coronary stenting. Am J Cardiol, 2005, 96: 1410-1415.
16.	Ross AM, Gibbons RJ, Stone GW, et al. A randomized, double-blinded, placebo-controlled multicenter trial of adenosine as an adjunct to reperfusion in the treatment of acute myocardial infarction (AMISTAD-II). J Am Coll Cardiol, 2005, 45: 1775-1780.
17.	Cohen DJ, Murphy SA, Baim DS, et al. Cost-effectiveness of distal embolic protection for patients undergoing percutaneous intervention of saphenous vein bypass grafts: results from the SAFER trial. J Am Coll Cardiol, 2004, 44: 1801-1808.
18.	范衛澤, 傅向華, 姜云發, 等. 冠狀動脈內應用山莨菪堿對急性心肌梗死介入治療后無再流及心室功能和收縮同步性的影響. 中華心血管病雜志, 2007, 27(4): 762-764.
19.	陳金良, 傅向華, 范衛澤, 等. 冠脈內注射山莨菪堿及腺苷對急性心肌梗死患者介入治療后緩再流現象的影響. 中華高血壓雜志, 2008, 16(4): 340-343.
20.	陳金良, 傅向華, 姜云發, 等. 烏拉地爾對急性前壁心肌梗死介入治療后心肌無復流患者心室功能和收縮同步性的影響. 中國危重病急救雜志, 2008, 20(4): 197-199.
21.	范衛澤, 傅向華, 谷新順, 等. 冠狀動脈內單用替羅非班與聯合應用山莨菪堿對急性心肌梗死經皮冠狀動脈介入治療后無再流現象影響的對比研究. 臨床心血管病雜志, 2007, 23（6）：423-426.
22.	危小軍, 廖偉, 鐘一鳴, 等. 應用尿激酶和(或)維拉帕米改善經皮冠脈介入治療時無再流現象的療效及安全性評價. 中國急救醫學, 2006, 26（12）：901-903.
23.	汪蔚青, 金惠根, 蔣金法, 等. 尿激酶對直接經皮冠狀動脈介人治療術后無復流患者的療效觀察. 上海醫學, 2006, 29(10): 711-714.
24.	Vijayalakshmi K, Whittaker VJ, Kunadian B, et al. Prospective, randomised, controlled trial to study the effect of intracoronary injection of verapamil and adenosine on coronary blood flow during percutaneous coronary intervention in patients with acute coronary syndromes. Heart, 2006, 92: 1278-1284.
25.	劉君, 傅向華, 馬寧. 等. 急性心肌梗死經皮冠狀動脈介入治療后心肌灌注分級無再流現象對心室功能和收縮同步性的影響. 中華心血管病雜志, 2004, 32(10): 874-878.
26.	韓艷麗, 陳玉國, 李貴雙, 等. 小劑量尿激酶聯合合貝爽冠狀動脈內注射對PCI無再流現象療效的臨床評價. 中國中西醫結合影像學雜志, 2003, 1(4): 209-214.
27.	Parikh KH, Chag MC, Shah KJ, et al. Intracoronary boluses of adenosine and sodium nitroprusside in combination reverses slow/no-reflow during angioplasty: a clinical scenario of ischemic preconditioning. Canadian Journal of Physiology and Pharmacology, 2007, 85(3-4): 476-482.

1. Zijlstra F, de Boer MJ, Hoorntje JC, et al. A comparison of immediate coronary angioplasty with intravenous streptokinase in acute myocardial infarction. N Engl J Med, 1993, 328: 680-684.
2. Weaver WD, Simes RJ, Betriu A, et al. Comparison of primary coronary angioplasty and intravenous thrombolytic therapy for acute myocardial infarction: a quantitative review. JAMA, 1997, 278: 2093-2098.
3. Keeley EC, Boura JA, Grines CL. Primary angioplasty versus intravenous thrombolytic therapy for acute myocardial infarction: a quantitative review of 23 randomised trials. Lancet, 2003, 361: 13-20.
4. Abbo KM, Dooris M, Glazier S, et al. Features and outcome of no-reflow after percutaneous coronary intervention. Am J Cardiol, 1995, 75: 778-782.
5. Resnic FS, Wainstein M, Lee MK, et al. No-reflow is an independent predictor of death and myocardial infarction after percutaneous coronary intervention. Am Heart J, 2003, 145: 42-46.
6. Piana RN, Paik GY, Moscucci M, et al. Incidence and treatment of ’no-reflow’ after percutaneous coronary intervention. Circulation, 1994, 89: 2514-2518.
7. Mizote I, Ueda Y, Ohtani T, et al. Distal protection improved reperfusion and reduced left ventricular dysfunction in patients with acute myocardial infarction who had angioscopically defined ruptured plaque. Circulation, 2005, 1001-1007.
8. Laude K, Beauchamp P, Thuillez C, et al. Endothelial protective effects of preconditioning. Cardiovasc Res, 2002, 55: 466-473.
9. Kemper AJ, O’Boyle JE, Cohen CA, et al. Hydrogen peroxide contrast echocardiography: quantification in vivo of myocardial risk area during coronary occlusion and of the necrotic area remaining after myocardial reperfusion. Circulation, 1984, 70: 309-317.
10. Topol EJ, Yadav JS. Recognition of the importance of embolization in atherosclerotic vascular disease. Circulation, 2000, 101: 570-580.
11. Eeckhout E, Kern MJ. The coronary no-reflow phenomenon: a review of mechanisms and therapies. Eur Heart J, 2001, 22: 729-739.
12. Herrmann J. Peri-procedural myocardial injury: 2005 update. Eur Heart J, 2005, 26: 2493-2519.
13. Assali AR, Sdringola S, Ghani M, et al. Intracoronary adenosine administered during percutaneous intervention in acute myocardial infarction and reduction in the incidence of "no reflow" phenomenon. Catheter Cardiovasc Interv, 2000, 51: 27-31; discussion 32.
14. Marzilli M, Orsini E, Marraccini P, et al. Beneficial effects of intracoronary adenosine as an adjunct to primary angioplasty in acute myocardial infarction. Circulation, 2000, 101: 2154-2159.
15. Micari A, Belcik TA, Balcells EA, et al. Improvement in microvascular reflow and reduction of infarct size with adenosine in patients undergoing primary coronary stenting. Am J Cardiol, 2005, 96: 1410-1415.
16. Ross AM, Gibbons RJ, Stone GW, et al. A randomized, double-blinded, placebo-controlled multicenter trial of adenosine as an adjunct to reperfusion in the treatment of acute myocardial infarction (AMISTAD-II). J Am Coll Cardiol, 2005, 45: 1775-1780.
17. Cohen DJ, Murphy SA, Baim DS, et al. Cost-effectiveness of distal embolic protection for patients undergoing percutaneous intervention of saphenous vein bypass grafts: results from the SAFER trial. J Am Coll Cardiol, 2004, 44: 1801-1808.
18. 范衛澤, 傅向華, 姜云發, 等. 冠狀動脈內應用山莨菪堿對急性心肌梗死介入治療后無再流及心室功能和收縮同步性的影響. 中華心血管病雜志, 2007, 27(4): 762-764.
19. 陳金良, 傅向華, 范衛澤, 等. 冠脈內注射山莨菪堿及腺苷對急性心肌梗死患者介入治療后緩再流現象的影響. 中華高血壓雜志, 2008, 16(4): 340-343.
20. 陳金良, 傅向華, 姜云發, 等. 烏拉地爾對急性前壁心肌梗死介入治療后心肌無復流患者心室功能和收縮同步性的影響. 中國危重病急救雜志, 2008, 20(4): 197-199.
21. 范衛澤, 傅向華, 谷新順, 等. 冠狀動脈內單用替羅非班與聯合應用山莨菪堿對急性心肌梗死經皮冠狀動脈介入治療后無再流現象影響的對比研究. 臨床心血管病雜志, 2007, 23（6）：423-426.
22. 危小軍, 廖偉, 鐘一鳴, 等. 應用尿激酶和(或)維拉帕米改善經皮冠脈介入治療時無再流現象的療效及安全性評價. 中國急救醫學, 2006, 26（12）：901-903.
23. 汪蔚青, 金惠根, 蔣金法, 等. 尿激酶對直接經皮冠狀動脈介人治療術后無復流患者的療效觀察. 上海醫學, 2006, 29(10): 711-714.
24. Vijayalakshmi K, Whittaker VJ, Kunadian B, et al. Prospective, randomised, controlled trial to study the effect of intracoronary injection of verapamil and adenosine on coronary blood flow during percutaneous coronary intervention in patients with acute coronary syndromes. Heart, 2006, 92: 1278-1284.
25. 劉君, 傅向華, 馬寧. 等. 急性心肌梗死經皮冠狀動脈介入治療后心肌灌注分級無再流現象對心室功能和收縮同步性的影響. 中華心血管病雜志, 2004, 32(10): 874-878.
26. 韓艷麗, 陳玉國, 李貴雙, 等. 小劑量尿激酶聯合合貝爽冠狀動脈內注射對PCI無再流現象療效的臨床評價. 中國中西醫結合影像學雜志, 2003, 1(4): 209-214.
27. Parikh KH, Chag MC, Shah KJ, et al. Intracoronary boluses of adenosine and sodium nitroprusside in combination reverses slow/no-reflow during angioplasty: a clinical scenario of ischemic preconditioning. Canadian Journal of Physiology and Pharmacology, 2007, 85(3-4): 476-482.

《中國循證醫學雜志》

藥物治療冠脈內支架置入術后無再流的系統評價

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《中國循證醫學雜志》

藥物治療冠脈內支架置入術后無再流的系統評價

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