Department of Medicine, Division of Cardiology, St Luke's-Roosevelt Hospital Center, Columbia University College of Physicians and Surgeons, New York, NY 10025, USA.
J Am Soc Echocardiogr. 2010 Aug;23(8):832-9. doi: 10.1016/j.echo.2010.05.004.
Stress echocardiography is an established technique for diagnosis, risk stratification, and prognosis in patients with known or suspected coronary artery disease. The ability of stress echocardiography to predict clinical outcomes, such as coronary angiography and revascularization, has not been reported previously. The purpose of this study was to evaluate the clinical outcomes of coronary angiography, revascularization, and cardiac events in patients undergoing stress echocardiography.
A total of 3121 patients (mean age, 60 + or - 13 years; 48% men) undergoing stress echocardiography (41% treadmill, 59% dobutamine) were assessed. Follow-up (mean, 2.8 + or - 1.1 years) for subsequent coronary angiography, revascularization (percutaneous coronary intervention [PCI] or coronary artery bypass grafting [CABG]), and confirmed hard events (nonfatal myocardial infarction or cardiac death) was obtained.
Stress echocardiographic results were normal (peak wall motion score index [pWMSI], 1.0) in 66% and abnormal (pWMSI > 1.0) in 34% of patients. The pWMSI effectively risk-stratified patients into low-risk (pWMSI, 1.0; 0.8% per year), intermediate-risk (pWMSI, 1.1-1.7; 2.6% per year), and high-risk (pWMSI >1.7; 5.5% per year) groups for future cardiac events (P < .0001). Early coronary angiography (30 days following stress echocardiography) was performed in only 35 patients (1.7%) with normal stress echocardiographic results and 267 patients (25.5%) with abnormal stress echocardiographic results (P < .0001). Late coronary revascularization (2 years following stress echocardiography) occurred in 80 patients (PCI, 2.8%; CABG, 1.1%) with pWMSI values of 1.0, 123 patients (PCI, 13.5%; CABG, 7.3%) with pWMSI values of 1.1 to 1.7, and 102 patients (PCI, 12.7%; CABG, 9.6%) with pWMSI values > 1.7. Multivariate logistic regression analysis identified pWMSI as a predictor of coronary angiography (relative risk, 2.04; 95% confidence interval, 1.67-2.5), revascularization (relative risk, 1.91; 95% confidence interval, 1.68-2.17), and cardiac events (relative risk, 2.45; 95% confidence interval, 2.09-2.88) (all P values < .0001). Patients with markedly abnormal stress echocardiographic results (pWMSI > 1.7) had a significantly higher cardiac event rate in those who did not undergo coronary revascularization (9.6% per year vs 2.9% per year, P < .05).
Stress echocardiography is an effective gatekeeper for coronary angiography and revascularization. Stress echocardiographic results influence clinical decision making in higher risk patients with significantly increased referral to coronary angiography and revascularization. Patients with markedly abnormal stress echocardiographic results (pWMSI > 1.7) were most likely to benefit from coronary revascularization.
应激超声心动图是一种用于诊断、风险分层和预后评估的技术，在已知或疑似冠状动脉疾病的患者中得到了广泛应用。然而，应激超声心动图在预测临床结局（如冠状动脉造影和血运重建）方面的能力尚未得到报道。本研究旨在评估接受应激超声心动图检查患者的冠状动脉造影、血运重建和心脏事件的临床结局。
共纳入 3121 例（平均年龄 60+/-13 岁，48%为男性）接受应激超声心动图检查（41%为平板运动试验，59%为多巴酚丁胺）的患者。平均随访 2.8+/-1.1 年，以评估随后的冠状动脉造影、血运重建（经皮冠状动脉介入治疗[PCI]或冠状动脉旁路移植术[CABG]）和确认的硬终点事件（非致死性心肌梗死或心脏性死亡）。
应激超声心动图结果正常（峰值壁运动评分指数[pWMSI]，1.0）的患者占 66%，异常（pWMSI>1.0）的患者占 34%。pWMSI 可有效将患者分为低危组（pWMSI，1.0；每年 0.8%）、中危组（pWMSI，1.1-1.7；每年 2.6%）和高危组（pWMSI>1.7；每年 5.5%），预测未来的心脏事件（P<0.0001）。早期冠状动脉造影（应激超声心动图后 30 天）仅在 35 例（1.7%）正常应激超声心动图结果和 267 例（25.5%）异常应激超声心动图结果的患者中进行（P<0.0001）。晚期冠状动脉血运重建（应激超声心动图后 2 年）发生在 80 例（PCI，2.8%；CABG，1.1%）pWMSI 值为 1.0、123 例（PCI，13.5%；CABG，7.3%）pWMSI 值为 1.1-1.7和 102 例（PCI，12.7%；CABG，9.6%）pWMSI 值>1.7的患者中。多变量逻辑回归分析显示，pWMSI 是冠状动脉造影（相对风险，2.04；95%置信区间，1.67-2.5）、血运重建（相对风险，1.91；95%置信区间，1.68-2.17）和心脏事件（相对风险，2.45；95%置信区间，2.09-2.88）的预测因素（所有 P 值均<0.0001）。pWMSI 明显异常（>1.7）且未行冠状动脉血运重建的患者，心脏事件发生率显著较高（每年 9.6% vs 每年 2.9%，P<0.05）。
应激超声心动图是冠状动脉造影和血运重建的有效“把关人”。应激超声心动图结果影响高风险患者的临床决策，明显增加了冠状动脉造影和血运重建的转诊率。pWMSI 明显异常（>1.7）的患者最有可能从冠状动脉血运重建中获益。
