Zacharias Konstantinos, Ahmed Asrar, Shah Benoy N, Gurunathan Sothinathan, Young Grace, Acosta Dionisio, Senior Roxy
Department of Cardiovascular Medicine and Institute for Medical Research, Northwick Park Hospital, Harrow, UK.
Centre for Health Informatics and Multi-Professional Education, University College London, London, UK.
Eur Heart J Cardiovasc Imaging. 2017 Feb;18(2):195-202. doi: 10.1093/ehjci/jew049. Epub 2016 Mar 24.
Exercise electrocardiography (ExECG) is widely used in suspected stable angina (SA) as the initial test for the evaluation of coronary artery disease (CAD). We hypothesized that exercise stress echo (ESE) would be efficacious with cost advantage over ExECG when utilized as the initial test.
Consecutive patients with suspected SA, without known CAD were randomized into ExECG or ESE. Patients with positive tests were offered coronary angiography (CA) and with inconclusive tests were referred for further investigations. All patients were followed-up for cardiac events (death, myocardial infarction, and unplanned revascularization). Cost to diagnosis of CAD was calculated by adding the cost of all investigations, up to and including CA. In the 194 and 191 patients in the ExECG vs. ESE groups, respectively, pre-test probability of CAD was similar (34 ± 23 vs. 35 ± 25%, P = 0.6). Results of ExECG were: 108 (55.7%) negative, 14 (7.2%) positive, 72 (37.1%) inconclusive and of ESE were 181 (94.8%) negative, 9 (4.7%) positive, 1 (0.5%) inconclusive, respectively. Patients with obstructive CAD following positive ESE vs. Ex ECG were 9/9 vs. 9/14, respectively (P = 0.04). Cost to diagnosis of CAD was £266 for ESE vs. £327 for ExECG (P = 0.005). Over a mean follow-up period of 21 ± 5 months, event rates were similar between the two groups.
In this first randomized study, ESE was more efficacious and demonstrated superior cost-saving, compared with ExECG when used as the initial investigation for the evaluation of CAD in patients with new-onset suspected SA without known CAD.
运动心电图（ExECG）在疑似稳定型心绞痛（SA）患者中被广泛用作评估冠状动脉疾病（CAD）的初始检查。我们假设，当用作初始检查时，运动负荷超声心动图（ESE）比ExECG更有效且具有成本优势。
将连续的疑似SA且无已知CAD的患者随机分为ExECG组或ESE组。检查结果阳性的患者接受冠状动脉造影（CA），检查结果不确定的患者则进行进一步检查。对所有患者进行心脏事件（死亡、心肌梗死和非计划性血运重建）随访。CAD的诊断成本通过累加直至包括CA在内的所有检查费用来计算。ExECG组和ESE组分别有194例和191例患者，CAD的预测试概率相似（34±23%对35±25%，P = 0.6）。ExECG的结果为：108例（55.7%）阴性，14例（7.2%）阳性，72例（37.1%）不确定；ESE的结果分别为181例（94.8%）阴性，9例（4.7%）阳性，1例（0.5%）不确定。ESE阳性与ExECG阳性后诊断为阻塞性CAD的患者分别为9/9例和9/14例（P = 0.04）。ESE诊断CAD的成本为266英镑，ExECG为327英镑（P = 0.005）。在平均21±5个月的随访期内，两组的事件发生率相似。
在这项首次随机研究中，对于新出现的疑似SA且无已知CAD的患者，当ESE用作评估CAD的初始检查时，与ExECG相比，ESE更有效且具有显著的成本节约优势。
