心肌梗塞和脑塞溶栓治疗的证据比较.doc

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 sugges