Cortigiani L, Picano E, Coletta C, Chiarella F, Mathias W, Gandolfo N, De Alcantara M, Mazzoni V, Gensini G F, Landi P
Unità Operativa de Malattie Cardiovascolari, Campo di Marte Hospital, 55032 Lucca, Italy.
Am Heart J. 2001 Apr;141(4):621-9. doi: 10.1067/mhj.2001.113997.
The outpatient prognostic assessment of coronary artery disease (CAD) by exercise electrocardiography has limitations, including the feasibility of the test and its low positive predictive value in several clinical conditions. In the current study we investigated the safety, feasibility, and prognostic value of pharmacologic stress echocardiography in a large cohort of ambulatory patients.
The study group was made of 1482 ambulatory patients (969 men, aged 60 +/- 10 years) who underwent stress echocardiography with either dipyridamole (n = 846) or dobutamine (n = 636) for evaluation of suspected or known stable CAD. The pretest likelihood of CAD was intermediate (<70%) in 709 patients and high (> or =70%) in 773 patients.
There was no complication during the dipyridamole test, whereas 2 ischemia-dependent, sustained ventricular tachycardias occurred during the dobutamine test. Limiting side effects were observed in 2% of dipyridamole and in 3% of dobutamine stresses. The echocardiogram was positive in 459 patients. During a mean follow-up of 28 +/- 24 months, 58 patients died, 33 had a nonfatal myocardial infarction, and 158 underwent early (< or =3 months) and 64 late (>3 months) revascularization. Multivariate predictors of hard events (death, infarction) were positive echocardiographic results (hazard ratio [HR] 2.9) and resting wall motion score index (WMSI) (HR 2.3). In considering major events (death, infarction, late revascularization) as end points, positive echocardiographic result (HR 4.3), scar (HR 2.2), and resting WMSI (HR 1.7) were independent prognostic predictors. The 5-year survival rates for the ischemic and nonischemic groups were, respectively, 80% and 91% (HR 3.6, 95% confidence interval [CI] 3.8-8.4; P <.0001) considering hard cardiac events and 65% and 88% (HR 2.6, 95% CI 2.1-5.9; P <.0001) considering major events. Multivariate predictors of major events were positive echocardiographic results (HR 8.2) and male sex (HR 2.5) for the intermediate-risk group and positive echocardiographic results (HR 2.9), resting WMSI (HR 1.8), and prior Q-wave myocardial infarction (HR 1.8) for the high-risk group.
Pharmacologic stress echocardiography is safe, highly feasible, and effective in prognostic assessment of ambulatory patients when both a general population and groups selected on the basis of pretest likelihood of CAD are analyzed. It represents a valid complementary tool to exercise electrocardiography for prognostic purposes in outpatients.
通过运动心电图对冠状动脉疾病（CAD）进行门诊预后评估存在局限性，包括检查的可行性以及在几种临床情况下其较低的阳性预测值。在本研究中，我们调查了药物负荷超声心动图在一大群门诊患者中的安全性、可行性和预后价值。
研究组由1482例门诊患者（969例男性，年龄60±10岁）组成，这些患者接受了双嘧达莫（n = 846）或多巴酚丁胺（n = 636）负荷超声心动图检查，以评估疑似或已知的稳定CAD。CAD的预测试验可能性在709例患者中为中等（<70%），在773例患者中为高（≥70%）。
双嘧达莫试验期间未出现并发症，而多巴酚丁胺试验期间发生了2例缺血依赖性持续性室性心动过速。双嘧达莫负荷试验和多巴酚丁胺负荷试验分别有2%和3%的患者出现了限制性副作用。459例患者的超声心动图结果为阳性。在平均28±24个月的随访期间，58例患者死亡，33例发生非致命性心肌梗死，158例接受了早期（≤3个月）和64例接受了晚期（>3个月）血运重建。严重事件（死亡、梗死）的多变量预测因素为超声心动图结果阳性（风险比[HR]2.9）和静息壁运动评分指数（WMSI）（HR 2.3）。将主要事件（死亡、梗死、晚期血运重建）作为终点进行分析时，超声心动图结果阳性（HR 4.3）、瘢痕（HR 2.2）和静息WMSI（HR 1.7）是独立的预后预测因素。考虑到严重心脏事件，缺血组和非缺血组的5年生存率分别为80%和91%（HR 3.6，95%置信区间[CI]3.8 - 8.4；P <.0001），考虑到主要事件则分别为65%和88%（HR 2.6，95%CI 2.1 - 5.9；P <.000）。主要事件的多变量预测因素在中危组为超声心动图结果阳性（HR 8.2）和男性（HR 2.5），在高危组为超声心动图结果阳性（HR 2.9）、静息WMSI（HR 1.8）和既往Q波心肌梗死（HR 1.8）。
当分析一般人群以及根据CAD预测试验可能性选择的组时，药物负荷超声心动图在门诊患者的预后评估中是安全、高度可行且有效的。它是运动心电图用于门诊患者预后评估的一种有效的补充工具。
