Marmur J D, Freeman M R, Langer A, Armstrong P W
St. Michael's Hospital, Toronto, Ontario.
Ann Intern Med. 1990 Oct 15;113(8):575-9. doi: 10.7326/0003-4819-113-8-575.
To assess the relative value of invasive and noninvasive predictors of outcome in patients after unstable angina.
Cohort of 54 patients with unstable angina who had 6-month follow-up after stabilization on medical therapy.
University-based hospital, tertiary referral center.
Consecutive patients with unstable angina whose symptoms resolved while receiving medical therapy.
We prospectively compared 24-hour Holter ST-segment monitoring at admission, quantitative exercise thallium tomography, and cardiac catheterization 5 +/- 2 days after admission and analyzed their value for predicting a cardiac event in patients with unstable angina within 6 months. When patients with a favorable outcome (n = 40) were compared with patients with an unfavorable outcome (n = 11) no statistical difference was found in duration of ST shift of 1 mm or more on Holter monitoring (51 +/- 119 min compared with 37 +/- 43 min), exercise duration by the standard Bruce protocol (8.0 +/- 3.6 min compared with 7.9 +/- 3.1 min), exercise-induced ST depression (0.6 +/- 0.9 mm compared with 1.0 +/- 1.0 mm), and contrast left ventricular ejection fraction (70% +/- 10% compared with 69% +/- 15%). Patients with a favorable outcome were distinguished from those with an unfavorable outcome by a higher maximum rate-pressure product (24 x 10(3) +/- 6 x 10(3) compared with 18 x 10(3) +/- 7 x 10(3), P = 0.0025), smaller size of the reversible scintigraphic perfusion defect expressed as a percentage of total myocardium imaged (6% +/- 11% compared with 17% +/- 18%, P = 0.05) and a smaller number of vessels with stenosis of 50% or more (1.1 +/- 1.2 compared with 2.1 +/- 1.0, P = 0.01). On multiple logistic regression analysis, a history of previous myocardial infarction was the most powerful predictor of outcome. In patients without myocardial infarction, reversible exercise thallium perfusion defect size was the only predictor.
After stabilization of an episode of unstable angina, quantitative tomographic exercise thallium scintigraphy has greater value for risk stratification than Holter ST-segment monitoring, particularly in patients who have not had a previous infarction.
评估不稳定型心绞痛患者预后的有创和无创预测指标的相对价值。
对54例不稳定型心绞痛患者进行队列研究，这些患者在接受药物治疗病情稳定后进行了6个月的随访。
大学附属医院，三级转诊中心。
连续入选的不稳定型心绞痛患者，其症状在接受药物治疗时缓解。
我们前瞻性地比较了入院时的24小时动态心电图ST段监测、定量运动铊断层扫描以及入院后5±2天的心脏导管检查，并分析了它们在预测不稳定型心绞痛患者6个月内发生心脏事件方面的价值。将预后良好的患者（n = 40）与预后不良的患者（n = 11）进行比较，结果发现动态心电图监测中ST段偏移≥1 mm的持续时间（分别为51±119分钟和37±43分钟）、标准Bruce方案的运动持续时间（分别为8.0±3.6分钟和7.9±3.1分钟）、运动诱发的ST段压低（分别为0.6±0.9 mm和1.0±1.0 mm）以及造影剂左心室射血分数（分别为70%±10%和69%±15%）均无统计学差异。预后良好的患者与预后不良的患者的区别在于前者最大心率-血压乘积更高（分别为24×10³±6×10³和18×10³±7×10³，P = 0.0025）、可逆性闪烁灌注缺损面积占总心肌成像面积的百分比更小（分别为6%±11%和17%±18%，P = 0.05）以及狭窄≥50%的血管数量更少（分别为1.1±1.2和2.1±1.0，P = 0.01）。多因素逻辑回归分析显示，既往心肌梗死病史是预后的最强预测指标。在无心肌梗死的患者中，可逆性运动铊灌注缺损面积是唯一的预测指标。
不稳定型心绞痛发作病情稳定后，定量运动铊断层扫描在危险分层方面比动态心电图ST段监测更有价值，尤其在既往无心肌梗死的患者中。
