Supino P G, Borer J S, Herrold E M, Hochreiter C
Division of Cardiovascular Pathophysiology, The Joan and Sanford I. Weill Medical College of Cornell University, The New York Presbyterian Hospital-Weill Cornell Medical Center, New York, NY 10021, USA.
Circulation. 1999 Aug 31;100(9):924-32. doi: 10.1161/01.cir.100.9.924.
Previous data indicate that left ventricular ejection fraction (LVEF) provides prognostic information among patients with coronary artery disease (CAD), but the value of such testing specifically for defining benefits of coronary artery bypass grafting (CABG) may relate to severity of exercise-inducible ischemia measured noninvasively before surgery.
To determine the independent prognostic importance of preoperative ischemia severity for predicting outcomes of CABG among patients with extensive CAD, we monitored 167 stable patients with angiographically documented 3-vessel CAD (average follow-up of 9 years in event-free patients) who previously had undergone rest and exercise radionuclide cineangiography. Their course was correlated with data obtained during initial radionuclide testing, coronary arteriography, and clinical evaluation at study entry. Fifty-two patients received medical treatment only, and 115 underwent CABG (44 early [</=1 month after initial study]). Multivariate Cox model analysis indicated that change (Delta) in LVEF from rest to exercise during radionuclide study was the strongest independent predictor of major cardiac events (P=0.003) before surgery and also predicted magnitude of CABG benefit (P=0.04). Patients with DeltaLVEF -8% or less derived significant survival-prolonging and event-reducing benefit from CABG performed </=1 month after initial testing (P<0.02 for cardiac death and P=0.008 for cardiac events], early CABG versus medical-treatment-only patients); similar benefits were absent among patients with DeltaLVEF more than -8%, and among those in whom CABG was deferred.
Assessment of ischemia severity based on LVEF response to exercise enables effective prognostication among patients with 3-vessel CAD and defines the likelihood of life-prolonging and event-reducing benefits from CABG.
既往数据表明，左心室射血分数（LVEF）可为冠心病（CAD）患者提供预后信息，但此类检测对于明确冠状动脉旁路移植术（CABG）获益的价值可能与术前通过无创检测测得的运动诱发缺血的严重程度有关。
为确定术前缺血严重程度对预测广泛CAD患者CABG预后的独立重要性，我们对167例经血管造影证实为三支血管CAD的稳定患者进行了监测（无事件患者的平均随访时间为9年），这些患者此前均接受过静息和运动放射性核素心血管造影检查。他们的病程与初始放射性核素检测、冠状动脉造影及研究入组时的临床评估所获得的数据相关。52例患者仅接受药物治疗，115例接受CABG（44例为早期手术[初始研究后≤1个月]）。多变量Cox模型分析表明，放射性核素研究期间从静息到运动时LVEF的变化（Δ）是术前主要心脏事件的最强独立预测因素（P = 0.003），并且还可预测CABG获益的程度（P = 0.04）。初始检测后≤1个月进行CABG的患者，其ΔLVEF≤ - 8%，在生存延长和事件减少方面有显著获益（心源性死亡P<0.02，心脏事件P = 0.008，早期CABG组与仅接受药物治疗的患者相比）；ΔLVEF> - 8%的患者以及CABG延期的患者未获得类似获益。
基于LVEF对运动的反应评估缺血严重程度，能够对三支血管CAD患者进行有效的预后评估，并确定CABG在延长生命和减少事件方面的获益可能性。
