Holley J L, Fenton R A, Arthur R S
Renal-Electrolyte Division, University of Pittsburgh, Pennsylvania 15213.
Am J Med. 1991 May;90(5):563-70.
This study assessed the usefulness of thallium stress testing as a predictor of perioperative cardiovascular risk in diabetic patients with end-stage renal disease undergoing cadaveric renal transplantation. Demographic factors influencing the exercise performance in these patients were also examined.
The medical records of 189 consecutive patients with diabetic nephropathy who were evaluated for cadaveric renal transplantation were reviewed. Thallium stress testing was the initial examination of cardiovascular status in 141 patients. An adequate examination was one in which at least 70% of maximum heart rate was achieved. A thallium stress test was normal if there were no ST segment depressions on the electrocardiogram and no perfusion abnormalities on the thallium scan. Forty-four patients underwent cardiac catheterization as the initial evaluation (Group C) and four patients underwent transplantation without a formal cardiovascular evaluation (Group D).
Sixty-four of the 141 patients undergoing thallium stress testing had an adequate and normal examination (Group A). The incidence of perioperative cardiac events in this group was 2%. Seventy-seven patients (Group B) had an abnormal (n = 41) or an inadequate (n = 36) thallium stress test and most (n = 61) then underwent coronary angiography. The use of beta-blockers was the only predictor of an abnormal or inadequate thallium stress test (10 of 64 versus 27 of 77, chi 2 = 6.66, p less than or equal to 0.025). Forty-three percent (26 of 61 in Group B) of patients with inadequate or abnormal thallium stress tests had significant coronary artery disease on cardiac catheterization. The perioperative risk of cardiac events was not different in Group A versus Groups B, C, and D combined. Survival of Group A and B patients was not different but was significantly longer than that of Group C patients (p less than 0.001). Thallium stress testing was less expensive than cardiac catheterization ($1,000 versus $4,000 to $5,000).
Thallium stress testing allowed 45% of patients to avoid cardiac catheterization before renal transplantation. Discontinuing beta-blockers before thallium stress tests may improve exercise performance. The risk of perioperative cardiac events after transplantation was low and not different among patient groups. The relatively low predictive value of thallium stress testing for significant coronary artery disease and perioperative cardiac events in diabetic patients with end-stage renal disease suggests the need for the development of a more cost-effective, noninvasive screening test for this patient population.
本研究评估了铊负荷试验作为预测接受尸体肾移植的终末期肾病糖尿病患者围手术期心血管风险的有用性。还研究了影响这些患者运动能力的人口统计学因素。
回顾了189例连续接受尸体肾移植评估的糖尿病肾病患者的病历。141例患者将铊负荷试验作为心血管状况的初步检查。充分的检查是指达到最大心率至少70%的检查。如果心电图上没有ST段压低且铊扫描没有灌注异常，则铊负荷试验结果正常。44例患者以心脏导管插入术作为初始评估（C组），4例患者未进行正式的心血管评估即接受了移植（D组）。
141例接受铊负荷试验的患者中，64例检查充分且结果正常（A组）。该组围手术期心脏事件的发生率为2%。77例患者（B组）铊负荷试验结果异常（n = 41）或不充分（n = 36），大多数患者（n = 61）随后接受了冠状动脉造影。使用β受体阻滞剂是铊负荷试验结果异常或不充分的唯一预测因素（64例中的10例与77例中的27例，χ² = 6.66，p≤0.025）。铊负荷试验结果不充分或异常的患者中，43%（B组61例中的26例）在心脏导管插入术中患有严重冠状动脉疾病。A组与B、C、D组合并组相比围手术期心脏事件风险无差异。A组和B组患者的生存率无差异，但显著长于C组患者（p＜0.001）。铊负荷试验比心脏导管插入术成本低（1000美元对4000至5000美元）。
铊负荷试验使45%的患者在肾移植前避免了心脏导管插入术。在铊负荷试验前停用β受体阻滞剂可能会改善运动能力。移植后围手术期心脏事件风险较低，且各患者组之间无差异。铊负荷试验对终末期肾病糖尿病患者严重冠状动脉疾病和围手术期心脏事件的预测价值相对较低，这表明需要为该患者群体开发一种更具成本效益的非侵入性筛查试验。
