术前多巴酚丁胺负荷超声心动图与非心脏手术后心脏风险评估的临床因素。
Preoperative Dobutamine Stress Echocardiography and Clinical Factors for Assessment of Cardiac Risk after Noncardiac Surgery.
机构信息
Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota.
Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota.
出版信息
J Am Soc Echocardiogr. 2020 Apr;33(4):423-432. doi: 10.1016/j.echo.2019.11.015. Epub 2020 Feb 20.
BACKGROUND
The role of dobutamine stress echocardiography (DSE) in the risk stratification of patients undergoing noncardiac surgery in the current era is unclear. The aim of this study was to evaluate the yield of DSE and the additive role of DSE to clinical criteria for preoperative risk stratification of patients undergoing noncardiac surgery.
METHODS
The study included 4,494 patients undergoing DSE ≤90 days before noncardiac surgery. The primary outcome was a composite of postoperative myocardial infarction, cardiac arrest, and all-cause mortality ≤30 days after noncardiac surgery.
RESULTS
The overall 30-day postoperative cardiac event rate was 2.3%. The mortality rate was 0.9% overall and 0.7% and 1.3% after normal and abnormal results on DSE, respectively. Among clinical variables, the modified Revised Cardiac Risk Index score demonstrated the strongest association with postoperative risk (P < .001). Patients with Revised Cardiac Risk Index scores of ≥3 had an event rate of 7.5%. The event rates for patients with wall motion score index ≥1.7 at baseline, left ventricular ejection fractions <40% at peak stress, or ischemic thresholds <70% of age-predicted maximal heart rate were 7.1%, 8.6%, and 7.9%, respectively. After adjusting for clinical variables, the overall result of DSE (P < .001), baseline and peak-stress wall motion score index (P < .001 and P = .014, respectively), peak-stress left ventricular ejection fraction (P < .001), and the number of ischemic segments (P = .027) were all associated with postoperative cardiac events. Incremental multivariate analysis demonstrated that an overall abnormal result on DSE, added to clinical variables, was associated with an increased risk for postoperative cardiac events (odds ratio, 2.07; 95% CI, 1.35-3.17; P < .001).
CONCLUSIONS
Baseline and peak-stress findings on preoperative DSE add to the prognostic utility of clinical variables for stratifying cardiac risk after noncardiac surgery.
背景
在当前时代，多巴酚丁胺负荷超声心动图（DSE）在非心脏手术患者风险分层中的作用尚不清楚。本研究旨在评估 DSE 的检出率以及 DSE 对非心脏手术患者术前风险分层的临床标准的附加作用。
方法
该研究纳入了 4494 例在非心脏手术前 90 天内进行 DSE 的患者。主要终点是术后 30 天内发生心肌梗死、心搏骤停和全因死亡的复合终点。
结果
总的 30 天术后心脏事件发生率为 2.3%。总体死亡率为 0.9%，DSE 正常和异常结果分别为 0.7%和 1.3%。在临床变量中，改良后的修订心脏风险指数评分与术后风险相关性最强（P<.001）。修订心脏风险指数评分≥3 的患者事件发生率为 7.5%。基线时壁运动评分指数≥1.7、峰值时左心室射血分数<40%或缺血阈值<70%预测最大心率的患者的事件发生率分别为 7.1%、8.6%和 7.9%。调整临床变量后，DSE 的整体结果（P<.001）、基线和峰值时壁运动评分指数（P<.001 和 P=.014）、峰值时左心室射血分数（P<.001）和缺血节段数（P=.027）均与术后心脏事件相关。多变量增量分析表明，DSE 的整体异常结果，加上临床变量，与术后心脏事件风险增加相关（比值比，2.07；95%置信区间，1.35-3.17；P<.001）。
结论
术前 DSE 的基线和峰值时发现可增加临床变量对非心脏手术后心脏风险分层的预测效用。
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