Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto, Ontario, Canada.
Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada; Women's College Hospital Institute for Health Systems Solutions and Virtual Care, Women's College Hospital, Toronto, Ontario, Canada.
J Am Soc Echocardiogr. 2020 Dec;33(12):1481-1489. doi: 10.1016/j.echo.2020.06.023. Epub 2020 Sep 3.
The association between appropriate use criteria for transthoracic echocardiography (TTE) and clinical outcomes is unknown for patients with valvular heart disease (VHD). The aim of this study was to identify the association of TTE appropriateness with downstream cardiac tests and clinical outcomes in patients with VHD over 365 days.
A subset of 2,297 patients with VHD across six Ontario academic hospitals was selected from the Echo WISELY (Will Inappropriate Scenarios for Echocardiography Lessen Significantly) trial and linked to administrative databases. Each patient's index TTE was classified as "rarely appropriate" (rA) versus "appropriate" (comprising "appropriate" and "may be appropriate" TTE according to the 2011 appropriate use criteria). Overall, 431 of 452 patients with rA TTE were matched 1:1 with patients with appropriate TTE using propensity scores to account for measured confounding.
Matched patients with rA TTE were less likely to undergo repeat TTE (relative risk, 0.46; 95% CI, 0.33-0.66) or cardiac catheterization (relative risk, 0.27; 95% CI, 0.16-0.47) at 90 days compared with patients with appropriate TTE. rA TTE was significantly associated with a decreased hazard of aortic valve intervention (hazard ratio, 0.40; 95% CI, 0.14-0.42), all-cause hospitalization (hazard ratio, 0.44; 95% CI, 0.34-0.57), and death (hazard ratio, 0.31; 95% CI, 0.15-0.66) over 365 days of follow-up.
Patients with appropriate TTE for VHD were more likely to undergo subsequent cardiac testing within 90 days and valve intervention within 1 year than those with a rA TTE. The 2011 appropriate use criteria for TTE have important clinical implications for outcomes in patient with VHD.
目前尚不清楚经胸超声心动图（TTE）的适用标准与瓣膜性心脏病（VHD）患者的临床结局之间的关系。本研究的目的是确定 TTE 适宜性与 VHD 患者 365 天内下游心脏检查和临床结局之间的关系。
从 Echo WISELY（Will Inappropriate Scenarios for Echocardiography Lessen Significantly，超声检查不适当情况是否会显著减少）试验中选择了安大略省六所学术医院的 2297 名 VHD 患者亚组，并将其与行政数据库相关联。每位患者的 TTE 都被归类为“罕见适宜”（rA）或“适宜”（根据 2011 年的适用标准，包括“适宜”和“可能适宜”的 TTE）。共有 452 名 rA TTE 患者中的 431 名患者通过倾向评分与适宜 TTE 患者进行了 1:1 匹配，以考虑测量的混杂因素。
与适宜 TTE 的患者相比，rA TTE 的患者在 90 天内行重复 TTE（相对风险，0.46；95%CI，0.33-0.66）或心脏导管检查（相对风险，0.27；95%CI，0.16-0.47）的可能性较小。rA TTE 与主动脉瓣介入的风险降低显著相关（风险比，0.40；95%CI，0.14-0.42）、全因住院（风险比，0.44；95%CI，0.34-0.57）和死亡（风险比，0.31；95%CI，0.15-0.66）的风险在 365 天的随访中降低。
VHD 患者的 TTE 适宜性较高的患者在 90 天内行后续心脏检查和瓣膜介入的可能性较高，而 rA TTE 患者的可能性较低。2011 年 TTE 的适用标准对 VHD 患者的结局具有重要的临床意义。
