Ross J, Gilpin E A, Madsen E B, Henning H, Nicod P, Dittrich H, Engler R, Rittelmeyer J, Smith S C, Viquerat C
Division of Cardiology, University of California, San Diego, La Jolla 92093.
Circulation. 1989 Feb;79(2):292-303. doi: 10.1161/01.cir.79.2.292.
It is important to select patients in the convalescent phase of acute myocardial infarction in whom knowledge of coronary anatomy may identify those potentially suitable for intervention aimed at improving prognosis. However, differing guidelines have been proposed, and by applying some of these guidelines to our large database of patients after acute myocardial infarction, several problem areas were identified. These include lack of considering patients with resting ischemia beyond day 5 of hospitalization, management of patients with reduced ventricular function or patients not exercise tested, and the role of coronary angiography in the elderly. Based on this experience and further analysis in 1,848 patients surviving beyond day 5 of hospitalization, a modified decision scheme for coronary angiography was developed and then tested in a second population (n = 780). In the new scheme, patients over 75 years of age are considered individually. Those under 75 years of age with severe resting ischemia in the hospital at any time beyond the first 24 hours (18% mortality between day 6 and year 1), and hospital survivors with a history of previous myocardial infarction and clinical or radiographic signs of left ventricular failure in the hospital (25% 1-year mortality after discharge), are recommended for coronary angiography. Among the remaining patients, some will perform an exercise test, and those with an ischemic response or poor workload (11% 1-year mortality) are also assigned to coronary angiography. When an exercise test is not performed, a resting radionuclide left ventricular ejection fraction is recommended, and coronary angiography is considered if the value lies between 0.20 and 0.44 (12% 1-year mortality). This relatively simple scheme does not make general recommendations in the elderly, considers patients with in-hospital left ventricular failure or reduced left ventricular function or both, and approaches the problem of patients who do not perform an exercise test. This general approach would avoid early coronary angiography in patients with an average 1-year mortality risk after discharge of 3% and recommend coronary angiography in those at increased risk (average mortality rate, 16%) who make up about 55% of this population under 75 years of age.
选择处于急性心肌梗死恢复期的患者很重要，在这些患者中，了解冠状动脉解剖结构可能有助于识别那些潜在适合进行旨在改善预后的干预措施的患者。然而，已经提出了不同的指导方针，通过将其中一些指导方针应用于我们的急性心肌梗死后患者的大型数据库，发现了几个问题领域。这些问题包括未考虑住院第5天以后仍有静息性缺血的患者、心室功能降低的患者或未进行运动试验的患者的管理，以及冠状动脉造影在老年人中的作用。基于这一经验以及对1848例住院第5天以后存活患者的进一步分析，制定了一种改良的冠状动脉造影决策方案，然后在另一组人群（n = 780）中进行了测试。在新方案中，对75岁以上的患者进行个体评估。75岁以下的患者，在入院后24小时后的任何时间出现严重静息性缺血（第6天至第1年的死亡率为18%），以及有心肌梗死病史且在医院有临床或影像学左心室衰竭体征的住院幸存者（出院后1年死亡率为25%），建议进行冠状动脉造影。在其余患者中，一些人将进行运动试验，有缺血反应或运动负荷不佳的患者（1年死亡率为11%）也被安排进行冠状动脉造影。如果不进行运动试验，建议进行静息放射性核素左心室射血分数检查，如果该值在0.20至0.44之间，则考虑进行冠状动脉造影（1年死亡率为12%）。这个相对简单的方案没有对老年人给出一般性建议，考虑了住院期间左心室衰竭或左心室功能降低或两者兼有的患者，并解决了未进行运动试验的患者的问题。这种总体方法将避免对出院后1年平均死亡风险为3%的患者进行早期冠状动脉造影，并建议对风险增加（平均死亡率为16%）的患者进行冠状动脉造影，这些患者约占75岁以下这一人群的55%。
