Ospedale San Luca, Via Guglielmo Lippi Francesconi, 55100, Lucca, Italy.
Biomedicine Department, CNR, Institute of Clinical Physiology, Pisa, Italy.
Intern Emerg Med. 2022 Oct;17(7):2103-2111. doi: 10.1007/s11739-022-03018-5. Epub 2022 Jul 21.
To estimate the prognostic value of stress echo (SE) with the assessment of coronary flow velocity reserve (CFVR) and heart rate reserve (HRR) in patients admitted for chest pain with non-diagnostic EKG, negative troponin, and without inducible regional wall motion abnormalities (RWMA). 658 patients (age 67 ± 12 years) admitted to our Emergency Department with chest pain, non-diagnostic EKG, and negative serial troponin underwent dipyridamole (0.84 mg/kg in 6') SE with simultaneous assessment of RWMA, CFVR in the left anterior descending artery, and HRR as peak/rest heart rate. The outcome measure was all-cause mortality. Of the 658 patients initially enrolled, 20 (3%) showed RWMA during SE and were referred to ischemia-driven revascularization. In the remaining 638, CFVR was abnormal (≤ 2.0) in 148 patients (23%). HRR was abnormal (≤ 1.22 in patients in sinus rhythm, or ≤ 1.17 in patients with permanent atrial fibrillation) in 196 patients (31%). During a follow-up of 7.3 ± 4.3 years, 151 (24%) patients died. Survival at 8 years was 93% in patients with normal CFVR and HRR, 76% in patients with abnormal CFVR only, 73% in patients with abnormal HRR only, and 38% in those with abnormal CFVR and HRR (p < 0.0001). At multivariable analysis, abnormal CFVR (HR 1.49, 95% CI 1.05-2.10, p = 0.02) and abnormal HRR (HR 2.01, 95% CI 1.43-2.84, p < 0.0001) were independent predictors of survival. In admitted patients with non-ischemic EKG, negative serial troponin, and without RWMA during dipyridamole SE, a reduced CFVR and blunted HRR independently identify a subset with worse survival in the long term. Upper panel: Color and pulsed-wave Doppler with the electrocardiographic lead tracing of Four different response patterns (from left to right): normal CFVR and HRR; normal CFVR, abnormal HRR; abnormal CFVR, normal HRR; abnormal CFVR and HRR. Lower panel: The annualized death rate for each of the four groups with negative SE for RWMA and stratified according to the presence of CFVR and HRR: none, one, or two abnormalities.
评估静息状态下超声心动图（SE），并结合冠状动脉血流储备（CFVR）和心率储备（HRR）评估，对心电图（EKG）非诊断性、肌钙蛋白阴性、且无诱导性局部室壁运动异常（RWMA）的胸痛患者的预后价值。658 例年龄（67±12）岁的胸痛患者因心电图非诊断性、连续肌钙蛋白阴性，行双嘧达莫（6'时 0.84mg/kg）SE 检查，同时评估左前降支的 RWMA、CFVR 和 HRR（心动高峰/静息时心率）。主要转归指标为全因死亡率。658 例患者中，20 例（3%）SE 时出现 RWMA，行缺血驱动血运重建。在其余 638 例中，148 例（23%）CFVR 异常（≤2.0）。196 例（31%）HRR 异常（窦性心律患者≤1.22，永久性房颤患者≤1.17）。随访 7.3±4.3 年期间，151 例（24%）患者死亡。CFVR 和 HRR 正常的患者 8 年生存率为 93%，CFVR 异常的患者为 76%，HRR 异常的患者为 73%，CFVR 和 HRR 均异常的患者为 38%（p<0.0001）。多变量分析显示，CFVR 异常（HR 1.49，95%CI 1.05-2.10，p=0.02）和 HRR 异常（HR 2.01，95%CI 1.43-2.84，p<0.0001）是生存的独立预测因子。在非缺血性心电图、连续肌钙蛋白阴性且 SE 期间无 RWMA 的入院患者中，CFVR 降低和 HRR 减弱可独立识别出长期预后较差的亚组。上图：彩色和脉冲多普勒与心电图导联描记的四个不同反应模式（从左到右）：正常 CFVR 和 HRR；正常 CFVR，异常 HRR；异常 CFVR，正常 HRR；异常 CFVR 和 HRR。下图：在 SE 检查无 RWMA 的情况下，根据 CFVR 和 HRR 的存在情况，对四个组（无、一个或两个异常）的年化死亡率进行分层：均无异常、有一个异常、有两个异常。
