目的：急性心肌梗塞静脉溶栓时，及早准确判断冠状动脉是否开通对判断预后及下一步治疗非常重要。冠状动脉造影是判断冠状动脉是否开通的主要手段。国内以往有关研究多以临床指标推断，多无同期冠状动脉造影对照，本研究目的旨在通过溶栓后90分冠状动脉造影心肌梗塞溶栓治疗临床试验(TIMI)血流结果对比评价临床无创指标的价值。

方法：1996～1998年期间入选中国rt-pa和尿激酶溶栓治疗对比研究(TUCC)中的219例资料较完整的首次急性心肌梗塞病人，根据溶栓后90分冠状动脉造影TIMI血流结果分为2组：再通组(TIMI血流2级、3级)141例；未通组(TIMI血流0级、1级)78例。主要观察临床无创指标内容包括：①抬高的心电图ST段下降≥50%的时间；②心肌酶活性(CK和CK-MB)峰值和达到峰值时间；③再灌注心律失常发生率及类型；④胸痛缓解达80%以上的各时段分布情况。另外，同时进行临床基础情况等比较。

结果：2组临床基础情况无明显差异，包括既往史，危险因素，梗塞史，梗塞部位，梗塞相关血管及冠状动脉病变支数，心脏功能等均无明显统计学差异。再通组30、60、90、120分平均ST段为0.39±0.30,0.30±0.23,0.24±0.21和0.19±0.46,而未通组则分别为0.44±0.25,0.42±0.27,0.39±0.24和0.35±0.32。除30分时段以外，2组均存在显著差异(P＜0.01)。再通组30、60、90、120分分别有35(25.7%),65(47.4%),91(68.9%),107(80.5%)例ST段下降达50%以上，未通组则分别为4(5.3%),13(17.1%),17(23.9%)和26(35.1%)。2组存在显著差异(P＜0.01)。再通组CK峰值(2 234.7±1 375.6 U/L)显著低于未通组(3 087.2±2 193.3，P＜0.01)。同样，CK-MB峰值再通组(159.4±123.3 U/L)也低于未通组(227.5±395.8 U/L)30、60、90分的敏感性和特异性分别为25.7%和94.7%,47.4%和82.9%,68.9%和76.1%(P＜0.05),再通组达到酶峰值时间(13.3±3.9小时)明显比未通组短(17.6±9.8小时，P＜0.01)。再通组74.5%发生再灌注心律失常，和未通组(46.6%)相比有显著差异，再通组82.3%病人溶栓后90分内胸痛缓解，明显高于未通组(44.8%,P＜0.01)。

结论：本研究提示临床无创指标可以预测再灌注和冠状动脉开通。尤其心电图抬高的ST段迅速下降和酶峰提前价值更大，有较高的敏感性和特异性。

A Study on Non-Invasive Markers in Comparison with Coronary Angiography in Acute Myocardial Infarction Patients Undergoing Thrombolytic Therapy (Abstract)

Division of Coronary Heart Disease, Cardiovascular Institute and Fu Wai Hospital, CAMS and PUMC, Beijing (100037)

Qin Xuewen, Gao Renlin, Chen Shuqing, et al.

Objective: Early reperfusion and sustained patency of the infarct-related coronary artery are important determinants of survival in patients with myocardial infarction. Althrough many clinical studies have been made to assess the value of non-invasive markers to predict coronary patency, only a limited number of studies prospectively assessed the role of non-invasive prediction strategy for early patency assessment in comparison with angiography in China. Therefore, we assessed the value of non-invasive markers to predict reperfusion and patency in the context of the angiography in TUCC substudy. The present prospectively designed study aimed to compare the predictive power of non-invasive markers with that of angiography for patency of infarct-related vessels after thrombolytic therapy.

Methods: In TUCC substudy, 219 patients with their first acute myocardial infarction underwent assessment of four non-invasive markers including ST segment monitoring, cardiac enzyme determinations, chest pain resolution and reperfuion arrhythmias. Simultaneous coronary angiography at 90 min following thrombolytic therapy was performed. The angiograms were evaluated for flow in infarct-related vessels using the classification of the thrombolysis in myocardial infarction trial (TIMI) at first injection of contrast agent. TIMI perfusion grade 0～1 indicated an occluded coronary artery, TIMI perfusion grade 2～3 a reopened artery. According to the TIMI perfusion grade, 219 patients were divided into two groups: Patency group, 141 cases; the occluded group, 78 cases. In order to evaluate the value of non-invasive markers, we compared and analyzed all clinical data and coronary angiograms in both groups, including complications and mortality. The study showed no difference in general clinical status between two groups, including age, risk factors, myocardial infarction location, infarct-related coronary artery, cardial function and blood pressure (p＞0.05).

Results: The study showed that ST segment recovery in patency group was very significant as compared with that in the occluded group (p＜0.01). Ninty-one patients (68.9%) in patency group had ≥50% ST recovery at 90 min after initiation of thrombolytic therapy, but only 17 patients (23.9%) in occluded group (p＜0.01). The sensitivity, specificity, positive and negative predictive rate at 90 min were 68.9%, 76.1%, 84.3% and 56.9%, respectively. The sensitivity and specificity were 25.7% and 94.7% at 30 min for a reduction of ST segment elevation ≥50%, and it was 80.5% and 64.9% at 120 min. Cardiac enzyme activity (CK and CK-MB) peak values in patency group were lower than in occluded group. The mean value for peak CK in patency group was 2 234.7±1 375.6 U/liter, and 3 087.2±2 193.3 U/liter in occluded group (p＜0.001). The mean value for CK-MB in patency group was 159.4±123.3 U/liter, and 227.5±395.8 in occluded group (p＜0.05). The time to peak value was 13.3±3.9 h in patency group, and 17.6±9.8 h in occluded groups (p＜0.01). The reperfusion arrhythmias were documented in 74.5% of patients in patency group, however, 46.6% in occluded group had reperfusion arrhythmias. There was significant difference between these two groups. The chest pain resolution was observed in 191 patients. 82.3% patients in patency group had a chest pain resolution at 90 min, only 44.8% in occluded group, there was statistical difference between two groups (p＜0.01).

Conclusion: We concluded that non-invasive makers may help toi predict reperfusion and coronary artery patency, especially ≥50% ST segment redution and early cardiac enzyme activity peak value and that permits accurate prediction of coronary patency in acute myocardial infarction undergoing thrombolytic therapy.