Department of Cardiology, Academic Medical Center Amsterdam, Amsterdam, the Netherlands,
Neth Heart J. 2011 Aug;19(7-8):324-30. doi: 10.1007/s12471-011-0154-9.
To determine the long-term prognostic value of stress imaging and clinical risk scoring for cardiovascular mortality in chest pain patients after ruling out acute coronary syndrome (ACS).
A standard rule-out protocol was performed in emergency room patients with a normal or non-diagnostic admission electrocardiogram (ECG) within 6 h of chest pain onset. ACS patients were identified by troponin T, recurrent angina and serial ECG. Dobutamine stress echocardiography (DSE) was performed after ACS was ruled out. Myocardial perfusion scintigraphy (MPS) was performed within 6 months in an outpatient setting according to the physician's discretion.
524 patients were included. GRACE and TIMI risk scores were 75 (57-96) and 1 (0-2) in the rule-out ACS group, and 89 (74-107) and 2 (1-3) in the ACS group, respectively (median, interquartile range). Follow-up (median 9.4 (8.9-10.0) years) was complete in 96%. 350 of 379 rule-out ACS patients had an interpretable DSE and 52 patients underwent an MPS. 21 of the rule-out ACS patients (6%) died of a cardiovascular cause compared with 24 (17%) ACS patients (p < 0.001). For rule-out ACS patients, C-statistics were 0.829 and 0.803 for the GRACE and TIMI scores. In these patients, DSE and MPS outcome did not predict long-term cardiovascular mortality. In multivariate analysis, known chronic heart failure, ACE inhibitor use, and GRACE score were independent predictors of cardiovascular mortality.
TIMI and GRACE score but not DSE and MPS are accurate predictors of long-term cardiovascular mortality, even in chest pain patients with a normal or non-diagnostic electrocardiogram undergoing a rule-out protocol.
确定在排除急性冠脉综合征（ACS）后，对胸痛患者进行应激成像和临床风险评分对心血管死亡率的长期预后价值。
对胸痛发作后 6 小时内心电图（ECG）正常或非诊断性入院的急诊室患者进行标准排除方案。通过肌钙蛋白 T、复发性心绞痛和连续 ECG 确定 ACS 患者。排除 ACS 后行多巴酚丁胺负荷超声心动图（DSE）检查。根据医生的判断，在门诊 6 个月内进行心肌灌注闪烁显像（MPS）。
共纳入 524 例患者。排除 ACS 组的 GRACE 和 TIMI 评分分别为 75（57-96）和 1（0-2），ACS 组分别为 89（74-107）和 2（1-3）（中位数，四分位间距）。96%的患者完成了中位随访 9.4（8.9-10.0）年。350 例排除 ACS 的患者可进行可解释的 DSE 检查，52 例患者进行 MPS 检查。与 24 例 ACS 患者（17%）相比，21 例排除 ACS 的患者（6%）死于心血管原因（p<0.001）。对于排除 ACS 的患者，GRACE 和 TIMI 评分的 C 统计量分别为 0.829 和 0.803。在这些患者中，DSE 和 MPS 结果并不能预测长期心血管死亡率。多变量分析显示，已知慢性心力衰竭、ACE 抑制剂的使用和 GRACE 评分是心血管死亡率的独立预测因素。
TIMI 和 GRACE 评分而不是 DSE 和 MPS 是预测长期心血管死亡率的准确指标，即使在进行排除方案的心电图正常或非诊断性胸痛患者中也是如此。
