Mehta Rajendra H, Rao Sunil V, Ohman E Magnus, Bates Eric R, Marcucci Gretchen, Zhang Min, Pieper Karen S, Armstrong Paul W, White Harvey D, Van de Werf Frans, Califf Robert M, Granger Christopher B
Duke Clinical Research Institute, Duke University Medical Center, Box 17969, Durham, NC 27715, USA.
Eur Heart J. 2008 Apr;29(7):880-7. doi: 10.1093/eurheartj/ehn100. Epub 2008 Mar 10.
Non-invasive risk stratification of low- and intermediate-risk non-ST-elevation acute coronary syndromes (NSTE ACS) patients has been recommended, but limited data exist about the variation in clinical practice of stress testing in these patients and the impact of such testing on their outcomes.
Patients with NSTE ACS enrolled in the GUSTO IIb (Global Use of Strategies To Open occluded coronary arteries in acute coronary syndromes-IIb) trial (n = 8011) were analysed to evaluate patterns of stress testing in US and non-US patients and to further evaluate the clinical characteristics, procedure use, and outcomes of patients who underwent stress testing compared with those who did not. Stress testing was performed in 1878 (24%) patients. Compared with patients not undergoing stress testing, those undergoing stress testing had low-risk characteristics and significantly lower death (0.6% vs. 4.8%), and death or myocardial infarction (MI, 3.9% vs. 11%) rates at 30 days. Stress testing was performed as often after as before coronary angiography. Importantly, stress testing was helpful in stratifying patients into low (equivocal or negative test) or high (positive test) risk groups (30 day death 3.1% vs. 5%). Stress testing was performed more often in non-US than US patients, and US patients were 3.5 times more likely to undergo imaging as part of stress testing. However, the risks of 30-day death or MI; 6-month death, MI or revascularization; and 1-year death did not differ between US and non-US patients.
Stress testing is commonly performed in low-risk NSTE ACS patients and provides modest additional prognostic information in this cohort. Significant geographical variation exists in the use of stress testing. Therefore, in the current practice environment where cardiac catheterization is often the first diagnostic modality used in patients with NSTE ACS, the role of non-invasive testing both before and after invasive procedure is in need of further study.
已推荐对低危和中危非ST段抬高型急性冠状动脉综合征（NSTE ACS）患者进行非侵入性风险分层，但关于这些患者负荷试验临床实践的差异以及此类试验对其预后的影响的数据有限。
对纳入GUSTO IIb（急性冠状动脉综合征中开放闭塞冠状动脉策略的全球应用-IIb）试验的8011例NSTE ACS患者进行分析，以评估美国和非美国患者的负荷试验模式，并进一步评估接受负荷试验的患者与未接受负荷试验的患者的临床特征、检查使用情况和预后。1878例（24%）患者进行了负荷试验。与未进行负荷试验的患者相比，进行负荷试验的患者具有低危特征，30天时死亡（0.6%对4.8%）、死亡或心肌梗死（MI，3.9%对11%）发生率显著更低。负荷试验在冠状动脉造影前后进行的频率相同。重要的是，负荷试验有助于将患者分为低危（试验结果不明确或阴性）或高危（试验结果阳性）组（30天死亡率3.1%对5%）。非美国患者进行负荷试验的频率高于美国患者，美国患者进行负荷试验时接受成像检查的可能性是非美国患者的3.5倍。然而，美国和非美国患者30天死亡或MI、6个月死亡、MI或血运重建以及1年死亡的风险并无差异。
低危NSTE ACS患者常进行负荷试验，且为此类患者群体提供了适度的额外预后信息。负荷试验的使用存在显著的地域差异。因此，在当前心脏导管插入术常作为NSTE ACS患者首要诊断方式的实践环境中，侵入性检查前后非侵入性检查的作用有待进一步研究。
