Cortigiani Lauro, Coletta Claudio, Bigi Riccardo, Amici Elisabetta, Desideri Alessandro, Odoguardi Leonardo
Cardiology Division, Campo di Marte Hospital, 55032 Lucca, Italy.
Am J Cardiol. 2003 Apr 15;91(8):941-5. doi: 10.1016/s0002-9149(03)00108-5.
Exercise electrocardiography (ECG) is of limited usefulness in hypertensive patients, whereas pharmacologic stress echocardiography can provide diagnostic and prognostic information. The aim of this study was to compare the prognostic value of clinical data, exercise ECG, and pharmacologic stress echocardiography in hypertensive patients with chest pain and to identify the best strategy for their risk stratification. Three hundred sixty-seven hypertensive patients (189 men, age 61 +/- 9 years) with chest pain of unknown origin underwent exercise ECG and pharmacologic stress echocardiography (237 with dipyridamole and 130 with dobutamine) and were followed up for 31 +/- 24 months. Positive exercise ECG (ST-segment shift of > or =1 mm at 80 ms after the J point) and stress echocardiography (new wall motion abnormalities) were found in 130 (35%) and 86 (23%) patients, respectively. During follow-up, there were 13 deaths and 16 myocardial infarctions. Additionally, 43 patients underwent coronary revascularization and were censored accordingly. Of 12 clinical, electrocardiographic, and echocardiographic variables analyzed, a positive result of stress echocardiography was the only multivariate predictor of either death (hazard ratio [HR] 4.7, 95% confidence interval [CI] 1.5 to 14.5, p = 0.007) or hard events (death, myocardial infarction) (HR 4.1, 95% CI 1.8 to 9.3, p = 0.0009). Using an interactive stepwise procedure, stress echocardiography provided additional prognostic information to clinical evaluation and exercise ECG. However, the negative predictive value of the 2 tests was similarly (p = NS) high in assessing 4-year event-free survival. In conclusion, a negative exercise electrocardiographic test identifies low-risk hypertensive patients with chest pain and should be the first-line approach for risk stratification. In contrast, positive exercise ECG is unable to distinguish between patients with different levels of risk. In this case, stress echocardiography provides strong and incremental prognostic power over clinical and exercise electrocardiographic data.
运动心电图（ECG）对高血压患者的作用有限，而药物负荷超声心动图可提供诊断和预后信息。本研究的目的是比较临床资料、运动心电图和药物负荷超声心动图在有胸痛的高血压患者中的预后价值，并确定对其进行危险分层的最佳策略。367例病因不明的胸痛高血压患者（189例男性，年龄61±9岁）接受了运动心电图和药物负荷超声心动图检查（237例用双嘧达莫，130例用多巴酚丁胺），并随访31±24个月。分别有130例（35%）和86例（23%）患者运动心电图阳性（J点后80毫秒ST段偏移≥1毫米）和负荷超声心动图阳性（新出现的室壁运动异常）。随访期间，有13例死亡和16例心肌梗死。此外，43例患者接受了冠状动脉血运重建并相应进行了截尾。在分析的12项临床、心电图和超声心动图变量中，负荷超声心动图阳性是死亡（风险比[HR]4.7，95%置信区间[CI]1.5至14.5，p = 0.007）或严重事件（死亡、心肌梗死）（HR 4.1，95%CI 1.8至9.3，p = 0.009）的唯一多变量预测因素。采用交互式逐步法，负荷超声心动图为临床评估和运动心电图提供了额外的预后信息。然而，在评估4年无事件生存率时，这两种检查的阴性预测价值同样（p =无显著性差异）高。总之，运动心电图检查阴性可识别低风险的胸痛高血压患者，应作为危险分层的一线方法。相比之下，运动心电图阳性无法区分不同风险水平的患者。在这种情况下，负荷超声心动图比临床和运动心电图数据具有更强的预后预测能力。
