Picard Michael H, Saysana Kyle, Cyr Derek D, Zeng Xin, Scherrer-Crosbie Marielle, Shaw Leslee J, Senior Roxy, Poh Kian Keong, Bangalore Sripal, Leipsic Jonathon A, Mancini Gb John, Budoff Matthew J, Hague Cameron J, Min James K, O'Brien Sean M, Hochman Judith S, Maron David J, Reynolds Harmony R
Massachusetts General Hospital, Boston, Massachusetts; Harvard Medical School, Cambridge, Massachusetts.
Massachusetts General Hospital, Boston, Massachusetts; Harvard Medical School, Cambridge, Massachusetts.
J Am Soc Echocardiogr. 2025 Jun;38(6):465-481. doi: 10.1016/j.echo.2025.03.006. Epub 2025 Mar 18.
This study examined stress echocardiography in relation to coronary artery anatomy and outcome in subjects randomized in the International Study of Comparative Health Effectiveness with Medical and Invasive Approaches (ISCHEMIA) trial.
Of 5,179 patients randomized to initial invasive or conservative strategy, stress echocardiography was performed in 1,079. Coronary computed tomographic angiogram (CCTA) excluded left main disease and quantified coronary lesions. Degree of ischemia was defined by number of segments with stress-induced wall motion abnormalities (mild < 3, moderate = 3, and severe > 3). Transient ischemic dilation was defined as a 10% increase in stress left ventricular end-systolic volume. Primary end point was a composite of cardiovascular death, nonfatal myocardial infarction, or hospitalization for unstable angina, heart failure, or resuscitated cardiac arrest.
On CCTA, 607/715 (84%) with CCTA evaluable for ≥70% lesion had 1 such lesion. Features associated with coronary lesions ≥70% were number of ischemic/infarcted segments, 3 or more ischemic segments in the anterior territory, and inability to augment left ventricular ejection fraction 10 percentage points. Transient ischemic dilation, present in 28.5% of cases, was significantly associated with severity of ischemia. For every 0.10 increase in peak wall motion score index, there was a 12% increased risk of cardiovascular death or myocardial infarction (adjusted hazard ratio = 1.12; 95% CI, 1.04, 1.21; P = .003).
In patients with chronic coronary disease and moderate or severe myocardial ischemia receiving contemporary therapies, stress echocardiography identified subjects with significant coronary artery disease and wall motion score index provided prognostic value.
本研究在国际医学与侵入性方法比较健康效果研究（ISCHEMIA）试验中，对随机分组的受试者进行了负荷超声心动图检查，并将其与冠状动脉解剖结构及预后相关联。
在5179例随机接受初始侵入性或保守治疗策略的患者中，1079例接受了负荷超声心动图检查。冠状动脉计算机断层扫描血管造影（CCTA）排除左主干病变并对冠状动脉病变进行量化。缺血程度根据负荷诱发的室壁运动异常节段数量来定义（轻度<3个，中度=3个，重度>3个）。短暂性缺血性扩张定义为负荷状态下左心室收缩末期容积增加10%。主要终点是心血管死亡、非致死性心肌梗死或因不稳定型心绞痛、心力衰竭或心脏骤停复苏而住院的复合终点。
在CCTA上，715例中607例（84%）可评估≥70%病变的患者有1处此类病变。与≥70%冠状动脉病变相关的特征包括缺血/梗死节段数量、前壁区域3个或更多缺血节段以及左心室射血分数不能增加10个百分点。28.5%的病例存在短暂性缺血性扩张，其与缺血严重程度显著相关。每增加0.10的峰值室壁运动评分指数，心血管死亡或心肌梗死风险增加12%（调整后风险比=1.12；95%CI，1.04，1.21；P=0.003）。
在接受当代治疗的慢性冠状动脉疾病和中度或重度心肌缺血患者中，负荷超声心动图可识别出患有严重冠状动脉疾病的受试者，且室壁运动评分指数具有预后价值。
