Ladenheim M L, Kotler T S, Pollock B H, Berman D S, Diamond G A
Am J Cardiol. 1987 Feb 1;59(4):270-7. doi: 10.1016/0002-9149(87)90798-3.
The incremental ability of a clinical history, exercise electrocardiography (ECG) and myocardial perfusion scintigraphy to identify coronary events in the year after testing was assessed in 1,659 patients with symptoms suggestive of coronary artery disease (CAD), 74 of whom suffered a coronary event in the year after testing. Prognostic power was quantified in terms of the area under receiver operating characteristic curves derived from logistic regression. In 1,451 patients with normal rest ECG findings, a clinical history alone provided the most prognostic power (area = 72%). This improved significantly (by 5%) only when both tests were analyzed. In contrast, clinical history had significantly less prognostic power in the 208 patients with abnormal rest ECG findings (area = 58%), but each test then provided a significant incremental improvement in these patients (by 14% for each). A strategic model was thereby developed for prognostic assessment that recognizes the incremental power of these tests in specific patient groups as well as their overall accuracy and monetary cost. This strategy stratified individual patient risk for subsequent coronary events over a full order of magnitude (from 2 to 22%) at a 64% reduction in the cost of testing compared to performing both stress tests in all patients.
在1659例有冠状动脉疾病（CAD）症状的患者中，评估了临床病史、运动心电图（ECG）和心肌灌注闪烁扫描在检测后一年内识别冠状动脉事件的增量能力，其中74例在检测后一年内发生了冠状动脉事件。根据逻辑回归得出的受试者工作特征曲线下面积对预后能力进行量化。在1451例静息心电图结果正常的患者中，仅临床病史具有最强的预后能力（面积 = 72%）。仅当两项检查都进行分析时，预后能力才有显著提高（提高5%）。相比之下，在208例静息心电图结果异常的患者中，临床病史的预后能力显著较低（面积 = 58%），但每项检查在这些患者中都能显著提高预后能力（每项提高14%）。由此开发了一种用于预后评估的策略模型，该模型认识到这些检查在特定患者群体中的增量能力以及它们的总体准确性和成本。与对所有患者进行两项负荷试验相比，该策略将个体患者随后发生冠状动脉事件的风险分层了整整一个数量级（从2%到22%），同时检测成本降低了64%。
