Roghi A, Palmieri B, Crivellaro W, Sara R, Puttini M, Faletra F
Department of Cardiology, National Research Council, Niguarda Hospital, Milan, Italy.
Am J Cardiol. 1999 Jan 15;83(2):169-74. doi: 10.1016/s0002-9149(98)00819-4.
We evaluated whether a preoperative clinical algorithm allows an adequate stratification in cardiac risk and the predictive value of dipyridamole thallium-201 scintigraphy and rest echocardiography for postoperative adverse cardiac outcomes. Three hundred twenty patients undergoing 338 vascular surgery procedures were prospectively stratified into low, intermediate, and high risk. The low- and intermediate-risk patients underwent surgery without further diagnostic evaluation. In 7 high-risk patients the vascular procedure was canceled (1 died of myocardial infarction at 6-month follow-up), 9 underwent presurgical myocardial revascularization (1 died of myocardial infarction), and 49 underwent vascular surgery with perioperative intensive care treatment. Hospital mortality was 3.8%. Cardiac mortality and morbidity were 1.5% and 10.4%, respectively. We observed a significant difference in "hard" (death, myocardial infarction, pulmonary edema, major arrhythmias) and "soft" (myocardial ischemia, minor arrhythmias) events between groups, p <0.001. Previous pulmonary edema was a predictive variable of cardiac outcomes (multiple logistic regression analysis). Ninety-nine of 220 intermediate-risk patients randomly underwent dipyridamole thallium-201 scintigraphy: 37 had redistribution, 10 persistent, and 52 no defects; 7 of 13 soft and hard cardiac events occurred in patients without redistribution defects. Sensitivity, specificity, and positive and negative predictive values of redistribution defects for postoperative adverse outcomes were 38%, 63%, 14%, 87%, respectively. This algorithm may provide a safe and cost-effective approach (average cost saving per patient $1,500) to cardiac risk stratification. These results suggest that routine use of dipyridamole thallium-201 scintigraphy for screening of intermediate-risk patients may not be warranted.
我们评估了术前临床算法是否能对心脏风险进行充分分层，以及双嘧达莫铊-201心肌灌注显像和静息超声心动图对术后不良心脏结局的预测价值。320例接受338例血管外科手术的患者被前瞻性地分为低、中、高风险组。低风险和中风险患者在未进行进一步诊断评估的情况下接受手术。7例高风险患者取消了血管手术（1例在6个月随访时死于心肌梗死），9例接受了术前心肌血运重建（1例死于心肌梗死），49例接受了血管手术并接受围手术期重症监护治疗。医院死亡率为3.8%。心脏死亡率和发病率分别为1.5%和10.4%。我们观察到不同组之间在“硬”（死亡、心肌梗死、肺水肿、严重心律失常）和“软”（心肌缺血、轻微心律失常）事件上存在显著差异，p<0.001。既往肺水肿是心脏结局的预测变量（多因素逻辑回归分析）。220例中风险患者中的99例随机接受了双嘧达莫铊-201心肌灌注显像：37例有再分布，10例持续存在，52例无缺损；13例软硬心脏事件中有7例发生在无再分布缺损的患者中。再分布缺损对术后不良结局的敏感性、特异性、阳性预测值和阴性预测值分别为38%、63%、14%、87%。该算法可能为心脏风险分层提供一种安全且具有成本效益的方法（每位患者平均节省成本1500美元）。这些结果表明，对中风险患者进行双嘧达莫铊-201心肌灌注显像的常规筛查可能没有必要。
