Kulick D L, Rahimtoola S H
Cardiovasc Clin. 1990;21(1):3-25; discussion 26-9.
From the foregoing discussion, it becomes apparent that although noninvasive risk stratification is a reasonable approach to assessment of patients following an uncomplicated myocardial infarction, the performance of early cardiac catheterization and angiography on nearly all such patients is not unreasonable and may in fact be the most practical approach. The basis for this rationalization may be summarized as follows: 1. Many subgroups will need early catheterization anyway a. Myocardial infarction complicated by recurrent ischemia, heart failure, or complex ventricular arrhythmias b. Patients receiving thrombolytic treatment c. "Young" patients (less than 50 years old?) d. "Older" patients (over ages 65 to 70?) in otherwise good medical condition e. Patients unable to exercise f. Patients with abnormal or inconclusive noninvasive test results (approximately 70 percent of patients) 2. Cardiac catheterization and angiography as a single test provides the two most powerful prognostic variables following myocardial infarction, namely, the extent of coronary artery disease and residual left ventricular function. This knowledge is reassuring to both physician and patient and allows for planning of optimal long-term management. 3. Certain limitations exist in noninvasive risk assessment strategies. 4. This approach need not be significantly more costly, if all tests are used wisely. The major risk inherent in the definition of the extent of coronary artery disease in all survivors of acute myocardial infarction might be the performance of unnecessary revascularization procedures (percutaneous transluminal coronary angioplasty or coronary bypass surgery). The burden rests with the individual clinician to (1) collect all useful and necessary data; (2) assess reliability and accuracy of various tests available at one's own institution; (3) avoid performing unnecessary and repetitive tests; (4) interpret the data in the proper context; and (5) counsel patients appropriately, correctly, and judiciously about their prognosis and therapeutic options. In this manner, all patients who might benefit appropriately from revascularization can be discovered early and offered this therapeutic option. Other patients can also be managed more appropriately; for example, those who are truly at very low risk (normal left ventricular function and either normal coronary arteries or "mild" coronary artery disease). However, it is most important to avoid unnecessary revascularization procedures. Although this discussion has focused on noninvasive and invasive testing following myocardial infarction, it is necessary to emphasize that comprehensive management of coronary artery disease and its complications should not be neglected in these patients; for example, control or amelioration of risk factors for coronary artery disease is mandatory in all these patients, and in their families as well.
从上述讨论中可以明显看出，尽管无创风险分层是评估无并发症心肌梗死后患者的一种合理方法，但对几乎所有此类患者进行早期心脏导管插入术和血管造影并非不合理，实际上可能是最实用的方法。这种合理化的依据可总结如下：1. 许多亚组患者无论如何都需要早期导管插入术 a. 并发反复缺血、心力衰竭或复杂室性心律失常的心肌梗死 b. 接受溶栓治疗的患者 c. “年轻”患者（小于50岁？） d. “老年”患者（65至70岁以上？）且其他方面身体状况良好 e. 无法进行运动的患者 f. 无创检查结果异常或不确定的患者（约占患者的70%）2. 心脏导管插入术和血管造影作为一项单一检查可提供心肌梗死后两个最有力的预后变量，即冠状动脉疾病的程度和左心室残余功能。这一信息对医生和患者都能起到安慰作用，并有助于规划最佳的长期管理方案。3. 无创风险评估策略存在某些局限性。4. 如果明智地使用所有检查，这种方法不一定会显著增加成本。急性心肌梗死所有幸存者中冠状动脉疾病程度定义所固有的主要风险可能是进行不必要的血运重建手术（经皮腔内冠状动脉成形术或冠状动脉搭桥手术）。责任在于个体临床医生：(1) 收集所有有用且必要的数据；(2) 评估自己所在机构可用的各种检查的可靠性和准确性；(3) 避免进行不必要和重复的检查；(4) 在适当的背景下解读数据；(5) 就患者的预后和治疗选择向患者提供适当、正确且明智的建议。通过这种方式，所有可能从血运重建中适当获益的患者都能被早期发现并提供这种治疗选择。其他患者也能得到更适当的管理；例如，那些真正处于极低风险的患者（左心室功能正常且冠状动脉正常或为“轻度”冠状动脉疾病）。然而，避免不必要的血运重建手术最为重要。尽管本讨论聚焦于心肌梗死后的无创和有创检查，但必须强调，这些患者中冠状动脉疾病及其并发症的综合管理不应被忽视；例如，对所有这些患者及其家人而言，控制或改善冠状动脉疾病的危险因素是必不可少的。
