Vamvakidou Anastasia, Karogiannis Nikos, Tzalamouras Vasilis, Parsons Guy, Young Grace, Gurunathan Sothinathan, Senior Roxy
Department of Cardiovascular Medicine, Northwick Park Hospital, Watford Road, Harrow, HA1 3UJ, UK.
Department of Cardiology, Royal Brompton Hospital, London, UK.
Eur Heart J Cardiovasc Imaging. 2017 Apr 1;18(4):415-421. doi: 10.1093/ehjci/jew211.
Patients with symptomatic left bundle branch block (LBBB) may have myocardial ischaemia due to both coronary artery disease and/or cardiomyopathy (microcirculatory abnormalities) and may have concomitant left ventricular (LV) dysfunction. We aimed to assess the feasibility and prognostic value of contemporary stress echocardiography (SE), which can uncover both pathophysiologies in LBBB patients in routine clinical practice, and also aimed to assess the additive value of contrast SE.
Accordingly, 190 consecutive patients (age 70.5 ± 11.3 years, LV ejection fraction = 50.1 ± 10%) with symptomatic LBBB who underwent SE over 6 years were assessed, of which 142 (75%) underwent contrast SE and 176 (92.6%) had diagnostic SE. Inducible ischaemia was present in 25 (14.2%) patients. During follow-up (35.4 ± 20.2 months) there were 32 deaths (18%) and 18 (10.2%) first cardiovascular (CV) events (acute myocardial infarction/mortality) in the 176 patients with diagnostic studies. Wall thickening score index at peak stress (WTSIpeak), which measures combined LV function and inducible ischaemia, was an independent predictor of mortality (HR = 3.78, 95% CI = 1.39-10.31, P = 0.01) and CV events (HR = 3.96, 95% CI = 1.1-14.3, P = 0.036). An abnormal SE (myocardial ischaemia and/or abnormal LV function) predicted an almost three-fold increase in all-cause mortality and CV events compared with normal SE. Amongst the confounders affecting assessment of wall thickening in LBBB and conventional prognostic variables, use of contrast was an independent predictor (P = 0.034) of WTSI1.16 (optimal predictor of mortality/CV outcome).
SE in patients with LBBB demonstrated high feasibility and the combination of LV systolic function and myocardial ischaemia provided important prognostic information. Contrast-enhanced SE improved the prediction of outcome.
有症状的左束支传导阻滞（LBBB）患者可能因冠状动脉疾病和/或心肌病（微循环异常）而出现心肌缺血，且可能伴有左心室（LV）功能障碍。我们旨在评估当代负荷超声心动图（SE）在常规临床实践中揭示LBBB患者两种病理生理情况的可行性和预后价值，同时评估对比剂增强SE的附加价值。
因此，对连续6年接受SE检查的190例有症状LBBB患者（年龄70.5±11.3岁，左室射血分数=50.1±10%）进行了评估，其中142例（75%）接受了对比剂增强SE检查，176例（92.6%）进行了诊断性SE检查。25例（14.2%）患者存在诱发性缺血。在随访期间（35.4±20.2个月），176例接受诊断性检查的患者中有32例死亡（18%），18例（10.2%）发生首次心血管（CV）事件（急性心肌梗死/死亡）。负荷峰值时的室壁增厚评分指数（WTSIpeak）可衡量左室功能和诱发性缺血的综合情况，是死亡率（HR=3.78，95%CI=1.39-10.31，P=0.01）和CV事件（HR=3.96，95%CI=1.1-14.3，P=0.036）的独立预测因素。与正常SE相比，异常SE（心肌缺血和/或异常左室功能）预测全因死亡率和CV事件增加近三倍。在影响LBBB患者室壁增厚评估的混杂因素和传统预后变量中，使用对比剂是WTSI1.16（死亡率/CV结局的最佳预测因素）的独立预测因素（P=0.034）。
LBBB患者的SE显示出高可行性，左室收缩功能和心肌缺血的综合情况提供了重要的预后信息。对比剂增强SE改善了对结局的预测。
