Elhendy Abdou, Sozzi Fabiola, van Domburg Ron T, Bax Jeroen J, Schinkel Arend F L, Roelandt Jos R T C, Poldermans Don
Department of Internal Medicine, University of Nebraska Medical Centre, Omaha, Nebraska, USA.
Am J Cardiol. 2005 Aug 15;96(4):469-73. doi: 10.1016/j.amjcard.2005.04.004.
This study assessed the effect of ischemia during dobutamine stress echocardiography (DSE) on cardiac mortality in patients with heart failure. We studied 528 patients (62 +/- 11 years of age, 402 men) who had heart failure and previous myocardial infarction or known coronary artery disease and underwent DSE. Ischemia was defined as new or worsening wall motion abnormalities or a biphasic response. End point during follow-up was cardiac death. Mean ejection fraction was 35 +/- 12%. Ischemia was detected in 407 patients (77%). During a mean follow-up of 3.2 +/- 2.4 years, cardiac death occurred in 150 patients (28%). Myocardial revascularization was performed within 4 months after DSE in 117 patients (29%) who had ischemia. Annual rates of cardiac death were 4.8% in patients who did not have ischemia, 5.5% in those who had ischemia and underwent revascularization within 4 months, and 11.8% in those who had ischemia and were not revascularized (p <0.001 vs other groups). In a multivariate analysis model, independent predictors of cardiac death were diabetes (RR 2, 95% confidence interval 1.4 to 2.9), male gender (RR 1.7, 95% confidence interval 1.2 to 3.1), low-dose wall motion score index (RR 1.4, 95% confidence interval 1.2 to 2.6), and ischemia (RR 1.9, 95% confidence interval 1.3 to 3.2). Angina was not predictive of death. In patients who had ischemia, revascularization within 4 months after DSE was associated with decreased risk of cardiac death (RR 0.43, 95% confidence interval 0.3 to 0.8). In conclusion, myocardial ischemia that is detected by DSE is associated with increased risk of cardiac death among patients who have heart failure, after adjustment for left ventricular function. Patients who had ischemia and received revascularization within 4 months had a better survival than did patients who had ischemia and did not receive revascularization. Angina had no effect on prognosis. Therefore, patients who do not have angina should not be considered a lower-risk population if they have inducible ischemia.
本研究评估了多巴酚丁胺负荷超声心动图（DSE）期间的心肌缺血对心力衰竭患者心脏死亡率的影响。我们研究了528例患者（年龄62±11岁，男性402例），这些患者患有心力衰竭且既往有心肌梗死或已知冠状动脉疾病，并接受了DSE检查。心肌缺血定义为新出现或加重的室壁运动异常或双相反应。随访期间的终点是心源性死亡。平均射血分数为35±12%。407例患者（77%）检测到心肌缺血。在平均3.2±2.4年的随访期间，150例患者（28%）发生心源性死亡。117例（29%）有心肌缺血的患者在DSE后4个月内进行了心肌血运重建。无心肌缺血患者的心源性死亡年发生率为4.8%，有心肌缺血且在4个月内进行血运重建的患者为5.5%，有心肌缺血但未进行血运重建的患者为11.8%（与其他组相比，p<0.001）。在多变量分析模型中，心源性死亡的独立预测因素为糖尿病（相对风险2，95%置信区间1.4至2.9）、男性（相对风险1.7，95%置信区间1.2至3.1）、低剂量室壁运动评分指数（相对风险1.4，95%置信区间1.2至2.6）和心肌缺血（相对风险1.9，95%置信区间1.3至3.2）。心绞痛不能预测死亡。在有心肌缺血的患者中，DSE后4个月内进行血运重建与心源性死亡风险降低相关（相对风险0.43，95%置信区间0.3至0.8）。总之，经DSE检测到的心肌缺血与心力衰竭患者经左心室功能校正后的心脏死亡风险增加相关。有心肌缺血且在4个月内接受血运重建的患者比有心肌缺血但未接受血运重建的患者生存率更高。心绞痛对预后无影响。因此，没有心绞痛的患者如果存在可诱导的心肌缺血，不应被视为低风险人群。
