Shaw L J, Hachamovitch R, Heller G V, Marwick T H, Travin M I, Iskandrian A E, Kesler K, Lauer M S, Hendel R, Borges-Neto S, Lewin H C, Berman D S, Miller D
Emory University, Atlanta, Georgia 30322, USA.
Am J Cardiol. 2000 Jul 1;86(1):1-7. doi: 10.1016/s0002-9149(00)00819-5.
Effective allocation of medical resources in stable chest pain patients requires the accurate diagnosis of coronary artery disease and the stratification of future cardiac risk. We studied the relative predictive value for cardiac death of 3 commonly applied noninvasive strategies, clinical assessment, stress electrocardiography, and myocardial perfusion tomography, in a large, multicenter population of stable angina patients. The multicenter observational series comprised 7 community and academic medical centers and 8,411 stable chest pain patients. All patients underwent pretest clinical screening followed by stress (exercise 84% or pharmacologic 16%) electrocardiography and myocardial perfusion tomography. Risk-adjusted multivariable Cox proportional hazards models were developed to predict cardiac death. Kaplan-Meier rates of time to cardiac catheterization were also computed. Cardiac mortality was 3% during the 2.5 +/- 1.5 years of follow-up. The number of infarcted vascular territories and pretest clinical risk factors were strong predictors of cardiac mortality, whereas the number of ischemic vascular territories gained increasing importance when determining post-test resource use requirements (i.e., the decision to perform cardiac catheterization). Exertional ST-segment depression in a population with a high frequency of electrocardiographic abnormalities at rest was not a significant differentiator of cardiac death risk. Stable chest pain patients are accurately identified as being at high risk for near-term cardiac events by both physicians' screening clinical evaluation and by the results of stress myocardial perfusion imaging. Disease management strategies for stable chest pain patients aimed at risk reduction should incorporate knowledge of relevant end points in treatment and guideline development.
稳定型胸痛患者医疗资源的有效分配需要准确诊断冠状动脉疾病并对未来心脏风险进行分层。我们在一个大型多中心稳定型心绞痛患者群体中，研究了3种常用的非侵入性策略（临床评估、运动心电图和心肌灌注断层扫描）对心脏死亡的相对预测价值。该多中心观察性系列研究包括7个社区和学术医疗中心以及8411例稳定型胸痛患者。所有患者均接受了检查前的临床筛查，随后进行了负荷（84%为运动负荷，16%为药物负荷）心电图和心肌灌注断层扫描。我们建立了风险调整后的多变量Cox比例风险模型来预测心脏死亡。还计算了Kaplan-Meier心脏导管插入术时间发生率。在2.5±1.5年的随访期间，心脏死亡率为3%。梗死血管区域的数量和检查前的临床风险因素是心脏死亡率的强有力预测指标，而在确定检查后资源使用需求（即决定进行心脏导管插入术）时，缺血血管区域的数量变得越来越重要。在静息心电图异常发生率较高的人群中，运动时ST段压低并不是心脏死亡风险的显著区分因素。通过医生的筛查临床评估和负荷心肌灌注成像结果，稳定型胸痛患者能被准确识别为近期心脏事件的高危人群。旨在降低风险的稳定型胸痛患者疾病管理策略应纳入治疗和指南制定中相关终点的知识。
