Tarantini Luigi, Cioffi Giovanni, Di Lenarda Andrea, Valle Roberto, Pulignano Giovanni, Del Sindaco Donatella, Frigo Gianfranco, Soravia Giorgio, Tessier Renato, Catania Giuseppe
Dipartimento di Cardiologia, Ospedale San Martino, Belluno.
G Ital Cardiol (Rome). 2008 Dec;9(12):835-43.
Patients with asymptomatic left ventricular systolic dysfunction (ALVSD) have an increased risk of heart failure (HF) and a worse life expectancy. Since valuable therapies may prevent such dismal evolution, screening programs for ALVSD have recently been advocated to detect as early as possible such ominous condition. Echocardiography represents the gold standard for the assessment of ALVSD but its indiscriminate use in screening programs is impractical. Clinical multivariate risk assessment associated with ECG and serum brain natriuretic peptide (BNP) may be a feasible strategy to screen ALVSD. We prospectively sought to investigate the feasibility and effectiveness of a screening program for ALVSD based on ECG and BNP used in a hierarchical sequence in patients at high risk for HF.
Patients > or =55 years old with > or =2 risk factors for HF or > or =70 years old with > or =1 risk factor for HF entered the study performing sequentially ECG, BNP and echocardiographic evaluation. ALVSD was defined as a left ventricular ejection fraction < or =50%.
Thirty-three of 122 enrolled patients (27%) had ALVSD. They were older, presented more frequently a history of chemotherapy exposure, had often bundle branch block and higher BNP levels. No patient without any major abnormalities (atrial fibrillation, left ventricular hypertrophy, STT alterations of ischemic/strain origin, pathologic Q wave, bundle branch block) on ECG (n=31, 24.4%) had ALVSD. Among the 91 patients with abnormal ECG, ALVSD was observed in 33 (36%). The area under the receiver operating characteristic curve to detect ALVSD by BNP was 0.86 (confidence interval 0.79-0.94, p<0.0001) and BNP values of > or =43 pg/ml showed a sensitivity and a specificity of 94% and 57%, respectively. The proposed screening program was able to identify 95% (31/33) of patients with ALVSD saving 53% of echocardiographic examinations with a substantial reduction of the costs to diagnose ALVSD.
Our prospective investigation confirms that ECG and BNP may be useful in detecting ALVSD in high-risk patients. A cost-effective screening program based on such simple and low-cost diagnostic tests might be employed for the prevention of HF in primary and secondary prevention programs in high-risk patients.
无症状左心室收缩功能障碍（ALVSD）患者发生心力衰竭（HF）的风险增加，预期寿命较差。由于有价值的治疗方法可能预防这种不良进展，近来提倡开展ALVSD筛查项目以尽早发现这种不良状况。超声心动图是评估ALVSD的金标准，但在筛查项目中不加选择地使用它并不实际。与心电图（ECG）和血清脑钠肽（BNP）相关的临床多变量风险评估可能是筛查ALVSD的可行策略。我们前瞻性地研究了基于ECG和BNP按分层顺序用于HF高危患者的ALVSD筛查项目的可行性和有效性。
年龄≥55岁且有≥2个HF危险因素或年龄≥70岁且有≥1个HF危险因素的患者进入本研究，依次进行ECG、BNP和超声心动图评估。ALVSD定义为左心室射血分数≤50%。
122例入组患者中有33例（27%）患有ALVSD。他们年龄更大，更频繁地有化疗暴露史，常有束支传导阻滞且BNP水平更高。ECG无任何重大异常（房颤、左心室肥厚、缺血性/应变性起源的ST-T改变、病理性Q波、束支传导阻滞）的患者（n = 31，24.4%）均无ALVSD。在91例ECG异常的患者中，有33例（36%）观察到ALVSD。通过BNP检测ALVSD的受试者工作特征曲线下面积为0.86（置信区间0.79 - 0.94，p < 0.0001），BNP值≥43 pg/ml时，敏感性和特异性分别为94%和57%。所提出的筛查项目能够识别95%（31/33）的ALVSD患者，节省了53%的超声心动图检查，大幅降低了诊断ALVSD的成本。
我们的前瞻性研究证实，ECG和BNP可能有助于在高危患者中检测ALVSD。基于此类简单且低成本诊断检测的具有成本效益的筛查项目可用于高危患者一级和二级预防项目中的HF预防。
