急性冠心症治療的最新進展

Advances in the Therapy of Acute Coronary Syndrome

林鴻儒(Hung-Ju Lin) ； 陳明豐(Ming-Fong Chen)

《內科學誌》 19卷2期 (2008/04) Pp. 91-102

https://doi.org/10.6314/JIMT.2008.19(2).01

摘要

急性冠心症(acute coronary syndrome)的治療，可分成ST上升型心肌梗塞和非ST上升型急性冠心症。關於ST上升型心肌梗塞的治療，ASSENT-4PCI試驗本是希望能證實利用到院前注射全劑量血栓溶解劑的促進性經皮冠血管治療方式，來有效縮短心肌缺血的時間，結果卻反而增加併發症。在直接經皮冠血管治療過程中，經常性使用遠端保護及血栓摘除裝置，從臨床試驗結果看來，這些裝置不只沒有明顯臨床上的益處，而且安全性也是令人擔心。至於非ST上升型急性冠心症的治療，主要在於早期侵入性治療策略和選擇性侵入性治療策略上的探討。雖然在追蹤l年的ICTUS試驗發現這兩種治療處理方式並統計上無差異，不過有證據暗示，可能等到ICTUS長期的追蹤報告公佈才會有較明朗的結論。而對於抗血小板藥物和抗血栓凝結劑治療上，也有不同於以往的發現。幹細胞治療是醫學近來最受矚目的焦點，但以目前的臨床試驗的長期追蹤結果，卻無明顯增進左心室射出功率；至於有關是否能夠降低臨床併發症，目前並無一致的結論。幹細胞治療的重大突破，可能需要針對治療的機制作進一步了解。而治療的終極目標應該是從預防醫學的角度，利用目前基因體醫學的知識及技術，找出高危險群患者加以治療，以降低發生急性冠心症的機率。

關鍵字

急性冠心症 ； 促進性經皮冠血管治療 ； 抗血小板治療 ； 抗血栓凝結治療 ； 幹細胞治療 ； 基因體醫學

並列摘要

Acute coronary syndrome consists of two categories: ST-elevation myocardial infarction (STEMI) and non-ST-elevation acute coronary syndrome (NSTE ACS). Recent results of clinical trials relating to STEMI were focused at how to shorten myocardial ischemic time, and how to reduce the distal embolization resulting from primary percutaneous intervention (PCI). As to the former, ASSENT-4 PCI trial did not find facilitated PCI improved the clinical outcomes. As to the later, clinical trials about routine use of thrombectomy or distal protection devices did not have consistent results, and even some of them revealed the association with the routine use of the devices and the outcome of increased infarct area. Besides, whether early invasive strategy is better than selective invasive strategy in patients with NSTE ACS was not confirmed in the 1-year follow-up of ICTUS trial. The long-term result might be essential to the final conclusion. Up to date, clinical evidence on the stem cell-based therapy in STEMI treatment did not show the consistent and robust improvement of left ventricular ejection fraction or other clinical outcomes, no matter with infusion route of bone marrow cells or with subcutaneous injection of granulocyte-colony stimulating factor. More knowledge of mechanism of stem cell-based therapy may be needed to make a significant progress. In addition to exhaustive efforts to put the advances in therapy for acute coronary syndrome into clinical practice, utilizing the advances in genomic medicine might be a critical step to achieve the ultimate treatment goal-modifying environmental and genetic risks to avoid irreversible myocardial damage.

並列關鍵字

Acute coronary syndrome ； Facilitated percutaneous coronary intervention ； Antiplatelet therapy ； Anticoagulant therapy ； Stem cell-based therapy ； Genomic medicine