早期の血栓溶解療法とPTCAが急性心筋梗塞の進展阻止に有効であった一例

Effective thrombolytic therapy with transluminal coronary angioplasty to prevent the evolution of acute myocardial infarction at the very early stage

　Percutaneous Transluminal Coronary Pecanalization（PTCR）はRentropら^1）によって報告されて以来，急性心筋梗塞に対する有効な治療法として広く普及している^2,3）。一方Grüntzigら^4）によって開発されたPercuta—neous Transluminal Coronary Angioplasty （PTCA）は，その有効性，安全性が確立されつつあり^5,6），最近では狭心症だけでなく急性心筋梗塞にも応用されている^7〜9）。

　我々は，心筋梗塞の超急性期に，まず末梢静脈からのUrokinase （UK）注入により再疎通を得，そのあとPTCRとPTCAを併用することにより，心筋梗塞の進展を阻止することができ，非常に良好な結果が得られた症例を経験したのでここに報告する。

A 44-year-old man was admitted with a 1-hour history of severe chest pain. The admission ECG showed slight ST-segment elevation and peaked T-waves in leads V₁-V₄. Intravenous infusion of Uro-kinase (UK: 36×10⁴ IU) was performed immedi-ately after admission and in 30 minutes his chest pain was almost disappeared. A coronary angiogram (CAG) shortly after that showed a 90% stenosis (AHA classification) in the proximal portion of left anterior descending coronary artery (LAD). Be-cause severe coronary stenosis was present also after intracoronary infusion of UK (24×10⁴ IU), trans-luminal angioplasty (PTCA) was performed. Coro-nary stenosis was improved from 90 to 25%. Thirty minutes after PTCA the second attack with promi-nent ST-segment elevation in V₁-V₅ occurred. CAG showed complete occlusion at the same site of LAD. Recanalization with residual 50% stenosis was ob-tained after intracoronary UK (60×10⁴ IU). But 15 minutes later we experienced the second reocclusion of the LAD and performed intracoronary UK (72 ×10⁴ IU) and repeat PTCA. Again complete oc-clusion of the LAD was improved to less than 25% stenosis. After that he was free from recurrent at-tacks. The restudy 1 month later revealed complete patency of the LAD and normal wall motion of the left ventricle. Neither definite perfusion defect in Tl-201 scintigraphy nor development of abnormal Q waves were observed. This case suggests that sequen-tial thrombolytic therapy and PTCA performed at the early stage of acute myocardial infarction is effective to prevent the evolution of infarction.