1 Cardiovascular Ultrasound Imaging and Hemodynamic Laboratory, Department of Cardiovascular Medicine , Mayo Clinic, Rochester, Minnesota.
2 Division of Cardiovascular Diseases, Assiut University , Assuit, Egypt .
J Womens Health (Larchmt). 2018 May;27(5):542-551. doi: 10.1089/jwh.2017.6506. Epub 2018 Apr 19.
In women with low to intermediate risk of coronary artery disease (CAD), prognostic detection strategies have been controversial. We present the follow-up data of the SMART trial in peri/postmenopausal women at low to intermediate risk of CAD.
To determine the value of contrast stress echocardiography (CSE), stress electrocardiogram (sECG), and serum biomarkers for prediction of cardiovascular events (CE) in peri/postmenopausal women at low to intermediate risk of CAD.
From January 2004 to August 2007, 400 peri/postmenopausal women were prospectively enrolled. All women had detailed risk factor assessment, and underwent simultaneous CSE (Definity, Lantheus Medical Imaging) and sECG. Laboratories included brain natriuretic peptide (BNP), atrial natriuretic peptide, endothelin, and high sensitivity C-reactive protein. Wall motion score index was based on a 16-segment model. Abnormal CSE was defined as new or worsening wall motion abnormality at stress, while abnormal sECG was ≥1 mm horizontal/downsloping ST segment depression/elevation (80 mseconds duration). Self-reported outcome data were collected from a mailed Women's Heart Clinic Questionnaire. CE outcomes included all-cause mortality, nonfatal myocardial infarction (MI), heart failure, chest pain hospitalization or development of typical angina (CP), and revascularization (REVASC). Adjusted Cox proportional hazard ratios (HR; 95% confidence intervals) were reported.
A total of 366 women (54.4 ± 5.5 years, Framingham risk 6.5% ± 4.4%) completed simultaneous CSE and sECG. Forty-two (11.5%) had abnormal CSE, while sECG was abnormal in 22 (6%) women. Follow-up (4.4 ± 1.2 years) was available in 315/366 (86%) women (78% exercise-CSE, 22% dobutamine-CSE). In those who completed follow-up, CSE was abnormal in 33 women (10.5%) and sECG was abnormal in 21 (6.7%). In 33 women with abnormal CSE, sECG was abnormal in 7 (21.2%) and normal in 26 (79%), p = 0.0004. CE occurred in 27 (8.6%) women: 8 all-cause mortality, 2 nonfatal MI, 13 CP, and 4 REVASC. CE occurred in 21% versus 7% of women with abnormal versus normal CSE, p = 0.014 and 38% versus 6% of women with abnormal versus normal sECG, p < 0.0001. Rest BNP was higher in women with CE versus those without (p = 0.018). Abnormal sECG and abnormal CSE were associated with CE, while only abnormal sECG was an independent predictor of CE (adjusted HR 10.3 [1.9-61.4], p = 0.007). Of the laboratory results, only BNP was associated with CE (adjusted HR 2.9 [1.1-7.3], p = 0.028).
sECG and rest BNP were independent predictors of subsequent CE within 5 years in peri/postmenopausal women at low to intermediate risk of CAD.
在低至中度冠心病（CAD）风险的女性中，预后检测策略存在争议。我们报告了低至中度 CAD 风险的绝经后妇女 SMART 试验的随访数据。
确定对比应激超声心动图（CSE）、应激心电图（sECG）和血清生物标志物对低至中度 CAD 绝经后妇女心血管事件（CE）的预测价值。
从 2004 年 1 月至 2007 年 8 月，前瞻性纳入了 400 名绝经后妇女。所有女性均进行详细的危险因素评估，并同时进行 CSE（Definity，Lantheus Medical Imaging）和 sECG。实验室包括脑钠肽（BNP）、心钠肽、内皮素和高敏 C 反应蛋白。壁运动评分指数基于 16 节段模型。异常 CSE 定义为应激时新出现或恶化的壁运动异常，而异常 sECG 为≥1mm 水平/下斜 ST 段压低/抬高（80ms 持续时间）。通过邮寄女性心脏诊所问卷收集自我报告的结局数据。CE 结局包括全因死亡率、非致死性心肌梗死（MI）、心力衰竭、胸痛住院或典型心绞痛（CP）的发展以及血运重建（REVASC）。报告了调整后的 Cox 比例风险比（HR；95%置信区间）。
共有 366 名女性（54.4±5.5 岁，Framingham 风险 6.5%±4.4%）完成了同步 CSE 和 sECG。42 名（11.5%）的 CSE 异常，而 22 名（6%）的 sECG 异常。315/366（86%）名女性有可获得的随访（4.4±1.2 年）（78%为运动 CSE，22%为多巴酚丁胺 CSE）。在完成随访的女性中，33 名女性 CSE 异常（10.5%），21 名女性 sECG 异常（6.7%）。在 33 名 CSE 异常的女性中，7 名（21.2%）的 sECG 异常，26 名（79%）正常，p=0.0004。27 名女性（8.6%）发生 CE：8 例全因死亡率，2 例非致死性 MI，13 例 CP，4 例 REVASC。CE 在异常 CSE 女性中的发生率为 21%，在正常 CSE 女性中的发生率为 7%，p=0.014，CE 在异常 sECG 女性中的发生率为 38%，在正常 sECG 女性中的发生率为 6%，p<0.0001。CE 女性的静息 BNP 高于无 CE 女性（p=0.018）。异常 sECG 和异常 CSE 与 CE 相关，而只有异常 sECG 是 CE 的独立预测因子（调整后的 HR 10.3[1.9-61.4]，p=0.007）。在实验室结果中，只有 BNP 与 CE 相关（调整后的 HR 2.9[1.1-7.3]，p=0.028）。
在低至中度 CAD 风险的绝经后妇女中，sECG 和静息 BNP 是 5 年内发生后续 CE 的独立预测因子。
