Murray D P, Salih M, Tan L B, Murray R G, Littler W A
Br Heart J. 1987 Apr;57(4):313-8. doi: 10.1136/hrt.57.4.313.
An attempt was made to stratify risk of subsequent cardiac events in post-infarct patients according to a combination of the results of clinical assessment, routine diagnostic investigations, and pre-discharge exercise testing in 350 consecutive patients who were followed up for one year. Patients were classified prospectively on the basis of the extent of myocardial damage as assessed by peak enzyme release, reciprocal change on the electrocardiogram at the time of myocardial infarction, Norris prognostic index, ability to perform a pre-discharge exercise test (and test result), and ability to tolerate beta adrenergic blockade on discharge. Of the 50 patients with contraindications to pre-discharge exercise testing, 26% died or had reinfarctions compared with 9% of the 300 exercised patients; the 24 non-exercised patients with evidence of extensive myocardial damage or reciprocal changes on the electrocardiogram were particularly at risk. Similarly, among the 300 exercised patients, extensive myocardial damage, reciprocal change on the electrocardiogram, and ST depression on exercise testing were the major risk markers in that each identified at least 75% of the patients who had subsequent cardiac events. The 63 exercised patients who had all three of these major risk markers constituted a high risk group: 18 (29%) died or had reinfarction. Of the remaining 237 patients, only 9 (4%) had cardiac events. The 35 high risk patients with exercise induced angina pectoris or clinical contraindications to beta blockade were particularly at risk; 15 (43%) died or had reinfarction. This approach to risk stratification identified a small cohort of high risk patients in a large population of myocardial infarction survivors; it also identified a large group with a very low risk of subsequent cardiac events.
对350例连续心肌梗死患者进行了为期一年的随访，试图根据临床评估结果、常规诊断检查以及出院前运动试验结果的综合情况，对心肌梗死后患者后续发生心脏事件的风险进行分层。根据心肌损伤程度对患者进行前瞻性分类，评估指标包括酶峰值释放、心肌梗死时心电图的对应性改变、诺里斯预后指数、出院前进行运动试验的能力（以及试验结果），以及出院时耐受β肾上腺素能阻滞剂的能力。在50例有出院前运动试验禁忌证的患者中，26%死亡或再次发生心肌梗死，而在300例进行运动试验的患者中这一比例为9%；24例未进行运动试验但有广泛心肌损伤或心电图对应性改变证据的患者风险尤其高。同样，在300例进行运动试验的患者中，广泛心肌损伤、心电图对应性改变以及运动试验时ST段压低是主要的风险标志物，因为每一项指标都能识别出至少75%后续发生心脏事件的患者。63例具有所有这三项主要风险标志物的进行运动试验的患者构成了高危组：18例（29%）死亡或再次发生心肌梗死。在其余237例患者中，只有9例（4%）发生了心脏事件。35例有运动诱发心绞痛或β受体阻滞剂临床禁忌证的高危患者风险尤其高；15例（43%）死亡或再次发生心肌梗死。这种风险分层方法在大量心肌梗死幸存者中识别出了一小群高危患者；同时也识别出了一大群后续发生心脏事件风险极低的患者。
