Lin Grace A, Lucas F Lee, Malenka David J, Skinner Jonathan, Redberg Rita F
Division of General Internal Medicine, University ofCalifornia-San Francisco, 3333 California St, San Francisco, CA 94118, USA.
Circ Cardiovasc Qual Outcomes. 2013 May 1;6(3):309-14. doi: 10.1161/CIRCOUTCOMES.113.000138. Epub 2013 May 14.
Guidelines advise testing for ischemia, such as with stress testing, before elective percutaneous coronary intervention (PCI). However, pre-PCI stress testing is not always done; the implications of this practice are not known. Our objective was to evaluate whether receipt of stress testing before elective PCI predicts mortality.
Using claims data from a 20% random sample of Medicare beneficiaries, we identified patients who had elective PCI in 2004 and followed them for a median of 3.4 years (n=23 887). Cox proportional hazards models were used to test the relationship of pre-PCI stress testing to survival. Population-based rates of elective PCI and stress testing were calculated for 306 hospital referral regions and categorized into 4 groups: high stress test/high PCI, low stress test/low PCI, low stress test/high PCI, and high stress/low PCI regions. Cox modeling was used to test whether category of hospital referral regions is related to survival. Patients who underwent pre-PCI stress testing had a 13% lower risk of mortality than those who did not (adjusted hazard ratio, 0.87; 95% confidence interval, 0.81-0.92) after median follow-up of 3.4 years. Patients in low stress test/high PCI regions had a 14% higher risk of mortality than those in high stress test/high PCI regions (adjusted hazard ratio, 1.14; 95% confidence interval, 1.03-1.26).
Pre-PCI stress testing is associated with lower mortality in patients undergoing elective PCI. Greater adherence to guidelines with respect to documenting ischemia before elective PCI may result in improved outcomes for patients.
指南建议在择期经皮冠状动脉介入治疗（PCI）前进行缺血检测，如负荷试验。然而，PCI术前负荷试验并非总是进行；这种做法的影响尚不清楚。我们的目的是评估择期PCI前接受负荷试验是否可预测死亡率。
利用医疗保险受益人的20%随机样本的索赔数据，我们确定了2004年接受择期PCI的患者，并对他们进行了为期3.4年的中位数随访（n = 23887）。采用Cox比例风险模型来检验PCI术前负荷试验与生存之间的关系。计算了306个医院转诊区域的基于人群的择期PCI和负荷试验率，并将其分为4组：高负荷试验/高PCI、低负荷试验/低PCI、低负荷试验/高PCI和高负荷试验/低PCI区域。采用Cox模型来检验医院转诊区域类别是否与生存相关。在中位随访3.4年后，接受PCI术前负荷试验的患者的死亡风险比未接受者低13%（调整后的风险比，0.87；95%置信区间，0.81 - 0.92）。低负荷试验/高PCI区域的患者比高负荷试验/高PCI区域的患者死亡风险高14%（调整后的风险比，1.14；95%置信区间，1.03 - 1.26）。
PCI术前负荷试验与接受择期PCI的患者较低的死亡率相关。在择期PCI前更严格地遵循关于记录缺血情况的指南可能会改善患者的预后。
