对魁北克的80家医院中的心肌梗塞患者所接受治疗的一项调查表明，那些接受了直接经皮冠状动脉介入治疗（PPCI；如血管成形术）或纤溶治疗（即给予溶解血块药物的治疗）的患者，如果其治疗发生在的国际性治疗方针所建议的时间之后，那么患者在30天内发生死亡的风险会有显著增加；同时，发生死亡或在一年后因心肌梗塞或心衰而重新入院的综合后果的风险也会增加。
根据文章的背景资料，“直接经皮冠状动脉治疗和纤溶治疗都是在国际性的治疗方针中对STEMI的公认的疗法，其治疗裨益可在治疗的早期获得最大化。”STEMI（ST-段抬高性心肌梗塞）是在心肌梗塞之后在心电图上出现的某种图形。
Que-bec Healthcare Assessment Agency, Montreal, Canada的Laurie Lambert, Ph.D.及其同僚开展了一项对魁北克（人口780万）省内发生STEMI的评估以确定再灌注治疗（如PPCI或纤溶治疗）的应用和其延后以及在STEMI治疗方针所建议的时间范围外的再灌注治疗是否会与比建议所允许的延后治疗的结果更差有关联。研究人员分析了在2006-2007年期间，在魁北克的80家医院中的对STEMI进行的为期6个月的治疗数据。在国际性治疗方针中所建议的最长的延后时间为：PPCI为90分钟；纤溶治疗为30分钟。
在接受了急性再灌注治疗的病人中（n=1,832），有78.6%的人（1,440）接受了PPCI，有21.4%的人（392）接受了纤溶疗法。在那些接受了PPCI的患者中，从进门到气囊扩张的中位（中点）时间为110分钟。有68%的患者所接受的PPCI是不及时的（即超过了90分钟）。对那些接受了纤溶疗法的患者来说，他们的中位延误时间是33分钟，而未能及时治疗（即延误超过30分钟）的患者有54%。在1年的时候，综合型后果（即死亡或因为心衰或心肌梗塞而重新入院）的发生率在纤溶治疗的患者中为13.5%，在PPCI患者中为13.6%。
文章的作者写道：“当将这2种治疗组进行合并时，那些在所建议允许的延误范围之外的患者，其在30天时的校正死亡率会增加（6.6% vs. 3.3%）；在一年的时候，与那些接受了及时治疗的患者相比，这些患者的死亡风险的增加在统计学上不具显著性（9.3% vs. 5.2%）。那些在建议所允许的延后时间范围之外接受治疗的患者的1年时的死亡或再入院（因充血性心衰或急性心肌梗塞而再入院）的综合后果的校正风险较高（15.0 % vs. 9.2%）。在地区的层面上，经过校正之后，患者在建议的时间内接受治疗的人数每增加10%都与该地区30天时的总体死亡率下降有关。”
他们补充说，时间，而非再灌注的模式，看来是在这一系统性评估STEMI治疗中的一个关键性的决定因素。 “无论用什么再灌注策略，患者的治疗如果是在最大的建议所允许的延迟时间范围之外，其死亡率都会增加。”
原文出处：
JAMA. 2010;303(21):2148-2155.
Association Between Timeliness of Reperfusion Therapy and Clinical Outcomes in ST-Elevation Myocardial Infarction
Laurie Lambert, PhD; Kevin Brown, MSc; Eli Segal, MD; James Brophy, MD, PhD; Josep Rodes-Cabau, MD; Peter Bogaty, MD
Context Guidelines emphasize the importance of rapid reperfusion of patients with ST-elevation myocardial infarction (STEMI) and specify a maximum delay of 30 minutes for fibrinolysis and 90 minutes for primary percutaneous coronary intervention (PPCI). However, randomized trials and selective registries are limited in their ability to assess the effect of timeliness of reperfusion on outcomes in real-world STEMI patients.
Objectives To obtain a complete interregional portrait of contemporary STEMI care and to investigate timeliness of reperfusion and outcomes.
Design, Setting, and Patients Systematic evaluation of STEMI care for 6 months during 2006-2007 in 80 hospitals that treated more than 95% of patients with acute myocardial infarction in the province of Quebec, Canada (population, 7.8 million).
Main Outcome Measures Death at 30 days and at 1 year and the combined end point of death or hospital readmission for acute myocardial infarction or congestive heart failure at 1 year by linkage to Quebec's medicoadministrative databases.
Results Of 1832 patients treated with reperfusion, 392 (21.4%) received fibrinolysis and 1440 (78.6%) received PPCI. Fibrinolysis was untimely (>30 minutes) in 54% and PPCI was untimely (>90 minutes) in 68%. Death or readmission for acute myocardial infarction or heart failure at 1 year occurred in 13.5% of fibrinolysis patients and 13.6% of PPCI patients. When the 2 treatment groups were combined, patients treated outside of recommended delays had an adjusted higher risk of death at 30 days (6.6% vs 3.3%; odds ratio [OR], 2.14; 95% confidence interval [CI], 1.21-3.93) and a statistically nonsignificant increase in risk of death at 1 year (9.3% vs 5.2%; OR, 1.61; 95% CI, 1.00-2.66) compared with patients who received timely treatment. Patients treated outside of recommended delays also had an adjusted higher risk for the combined outcome of death or hospital readmission for congestive heart failure or acute myocardial infarction at 1 year (15.0% vs 9.2%; OR, 1.57; 95% CI, 1.08-2.30). At the regional level, after adjustment, each 10% increase in patients treated within the recommended time was associated with a decrease in the region-level odds of overall 30-day mortality (OR, 0.80; 95% CI, 0.65-0.98).
Conclusion Among patients in Quebec with STEMI, reperfusion delivered outside guideline-recommend delays was associated with significantly increased 30-day mortality, a statistically nonsignificant increase in 1-year mortality, and significantly increased risk of the composite of mortality or readmission for acute myocardial infarction or heart failure at 1 year.
