Poldermans Don, Bax Jeroen J, Schouten Olaf, Neskovic Aleksandar N, Paelinck Bernard, Rocci Guido, van Dortmont Laura, Durazzo Anai E S, van de Ven Louis L M, van Sambeek Marc R H M, Kertai Miklos D, Boersma Eric
Department of Anesthesiology, Erasmus Medical Center, Rotterdam, The Netherlands.
J Am Coll Cardiol. 2006 Sep 5;48(5):964-9. doi: 10.1016/j.jacc.2006.03.059. Epub 2006 Aug 17.
The purpose of this study was to assess the value of preoperative cardiac testing in intermediate-risk patients receiving beta-blocker therapy with tight heart rate (HR) control scheduled for major vascular surgery.
Treatment guidelines of the American College of Cardiology/American Heart Association recommend cardiac testing in these patients to identify subjects at increased risk. This policy delays surgery, even though test results might be redundant and beta-blockers with tight HR control provide sufficient myocardial protection. Furthermore, the benefit of revascularization in high-risk patients is ill-defined.
All 1,476 screened patients were stratified into low-risk (0 risk factors), intermediate-risk (1 to 2 risk factors), and high-risk (> or =3 risk factors). All patients received beta-blockers. The 770 intermediate-risk patients were randomly assigned to cardiac stress-testing (n = 386) or no testing. Test results influenced management. In patients with ischemia, physicians aimed to control HR below the ischemic threshold. Those with extensive stress-induced ischemia were considered for revascularization. The primary end point was cardiac death or myocardial infarction at 30-days after surgery.
Testing showed no ischemia in 287 patients (74%); limited ischemia in 65 patients (17%), and extensive ischemia in 34 patients (8.8%). Of 34 patients with extensive ischemia, revascularization before surgery was feasible in 12 patients (35%). Patients assigned to no testing had similar incidence of the primary end point as those assigned to testing (1.8% vs. 2.3%; odds ratio [OR] 0.78; 95% confidence interval [CI] 0.28 to 2.1; p = 0.62). The strategy of no testing brought surgery almost 3 weeks forward. Regardless of allocated strategy, patients with a HR <65 beats/min had lower risk than the remaining patients (1.3% vs. 5.2%; OR 0.24; 95% CI 0.09 to 0.66; p = 0.003).
Cardiac testing can safely be omitted in intermediate-risk patients, provided that beta-blockers aiming at tight HR control are prescribed.
本研究旨在评估术前心脏检查对于接受β受体阻滞剂治疗且心率（HR）控制严格、计划进行大血管手术的中危患者的价值。
美国心脏病学会/美国心脏协会的治疗指南建议对这些患者进行心脏检查，以识别风险增加的患者。这一政策会延迟手术，尽管检查结果可能多余，且严格控制心率的β受体阻滞剂已提供了足够的心肌保护。此外，高危患者血运重建的益处尚不明确。
所有1476例筛查患者被分为低危（0个危险因素）、中危（1至2个危险因素）和高危（≥3个危险因素）。所有患者均接受β受体阻滞剂治疗。770例中危患者被随机分为心脏负荷试验组（n = 386）或不进行试验组。试验结果影响治疗管理。对于有缺血的患者，医生旨在将心率控制在缺血阈值以下。对于有广泛应激性缺血的患者，考虑进行血运重建。主要终点是术后30天内心脏死亡或心肌梗死。
检查显示287例患者（74%）无缺血；65例患者（17%）有局限性缺血，34例患者（8.8%）有广泛缺血。在34例有广泛缺血的患者中，12例患者（35%）术前进行血运重建可行。未进行检查的患者与进行检查的患者主要终点发生率相似（1.8%对2.3%；比值比[OR]0.78；95%置信区间[CI]0.28至2.1；p = 0.62）。不进行检查的策略使手术提前了近3周。无论分配的策略如何，心率<65次/分钟的患者比其余患者风险更低（1.3%对5.2%；OR 0.24；95%CI 0.09至0.66；p = 0.003）。
对于中危患者，若开具旨在严格控制心率的β受体阻滞剂，则可安全地省略心脏检查。
