Kulick D L, Rahimtoola S H
Department of Medicine, University of Southern California School of Medicine, Los Angeles County 90033.
Am Heart J. 1991 Feb;121(2 Pt 1):641-56. doi: 10.1016/0002-8703(91)90747-6.
Noninvasive risk assessment in survivors of AMI can effectively subdivide patients into groups with differing risk profiles after hospital discharge, but some patients at risk for late death or recurrent AMI may be incorrectly identified; data from cardiac catheterization and angiography provide complementary and generally more powerful prognostic information. Many patients may derive particular benefit from early cardiac catheterization and angiography, including: (1) patients with AMI complicated by recurrent myocardial ischemia, congestive heart failure, and/or complex ventricular arrhythmias; (2) patients with abnormal or inconclusive results of noninvasive testing or those patients unable to perform an exercise test; (3) patients with abnormal left ventricular global systolic function and those with increased left ventricular end-systolic volume; (4) "young" patients (younger than 50 years of age?); (5) older patients (older than 65 to 70 years of age?); (6) patients with non-Q wave AMI; and (7) patients who are receiving thrombolytic therapy. Performance of early cardiac catheterization and angiography in virtually all survivors of AMI, with selective use of appropriate noninvasive tests, may provide a more efficacious means of risk assessment after AMI; if all tests are performed judiciously, the cost of such an approach need not be excessive. A combination of invasive and selected noninvasive tests probably provides optimal information. The risks to the routine performance of diagnostic cardiac catheterization and angiography in all survivors of AMI are: (1) adequate care and attention may not be paid to proper performance of the procedure(s) and to detailed and proper analyses of the data; (2) the need for additional noninvasive testing in selected patients may be ignored; and most importantly, (3) premature or unnecessary revascularization procedures may be performed subsequently. For optimal patient care, the clinician must obtain all necessary data, avoid unnecessary and repetitive tests, know the accuracy of individual tests at his or her own facility, interpret all data in proper context, and then counsel patients objectively about available management strategies. With this approach, all patients who might appropriately benefit from coronary artery revascularization will be correctly identified, and patients who are truly at very low risk (minimal residual coronary artery disease and preserved left ventricular function particularly if associated with a patent infarct-related artery) may be similarly identified and managed appropriately with elimination of unnecessary additional testing and pharmacologic therapy. Finally, whatever approach to risk stratification one chooses for an individual patient, the importance of and the need to correct and/or ameliorate risk factors for coronary artery disease must be recognized and undertaken.
对急性心肌梗死（AMI）幸存者进行无创风险评估可有效将患者在出院后分为具有不同风险特征的组，但一些有晚期死亡或复发性AMI风险的患者可能会被错误识别；心脏导管插入术和血管造影的数据提供了互补且通常更有力的预后信息。许多患者可能会从早期心脏导管插入术和血管造影中特别受益，包括：（1）伴有复发性心肌缺血、充血性心力衰竭和/或复杂室性心律失常的AMI患者；（2）无创检查结果异常或不确定的患者或无法进行运动试验的患者；（3）左心室整体收缩功能异常和左心室收缩末期容积增加的患者；（4）“年轻”患者（年龄小于50岁？）；（5）老年患者（年龄大于65至70岁？）；（6）非Q波AMI患者；以及（7）接受溶栓治疗的患者。对几乎所有AMI幸存者进行早期心脏导管插入术和血管造影，并选择性地使用适当的无创检查，可能会提供一种更有效的AMI后风险评估方法；如果所有检查都谨慎进行，这种方法的成本不一定过高。侵入性检查和选定的无创检查相结合可能会提供最佳信息。对所有AMI幸存者常规进行诊断性心脏导管插入术和血管造影的风险包括：（1）可能未对操作的正确执行以及数据的详细和正确分析给予充分的护理和关注；（2）可能会忽略在选定患者中进行额外无创检查的必要性；而最重要的是，（3）随后可能会进行过早或不必要的血运重建手术。为了实现最佳的患者护理，临床医生必须获取所有必要的数据，避免不必要和重复的检查，了解自己所在机构各项检查的准确性，在适当的背景下解读所有数据，然后客观地向患者提供可用的管理策略建议。通过这种方法，所有可能从冠状动脉血运重建中适当获益的患者都将被正确识别，而真正处于极低风险（残余冠状动脉疾病极少且左心室功能保留，特别是如果与梗死相关动脉通畅相关）的患者也可能被同样识别并得到适当管理，从而消除不必要的额外检查和药物治疗。最后，无论为个体患者选择何种风险分层方法，都必须认识到并着手纠正和/或改善冠状动脉疾病风险因素的重要性和必要性。
