Bigi R, Occhi G, Fiorentini C, Partesana N, Bandini P, Sponzilli C, Inglese L
Cardiac Rehabilitiation Unit, Regional Hospital, Sondalo (SO), Italy.
Int J Cardiol. 1995 Jun 2;50(1):51-60. doi: 10.1016/0167-5273(95)02326-r.
Our aim was to verify whether the sensitivity of pharmachological stress echocardiography for multivessel disease after acute myocardial infarction may be improved by a more aggressive protocol, i.e. not considering the appearance of the first wall motion abnormality as the absolute end-point if it occurs in the infarcted area without clinical or instrumental markers of extensive ischemia or left ventricular dysfunction. One-hundred twenty-one consecutive patients (age 32-71 years) prospectively underwent dobutamine-atropine stress echo (dobutamine infusion up to 40 micrograms/kg/min with additional atropine 1 mg) 11.8 +/- 4.8 days after uncomplicated myocardial infarction and coronary angiography within 6 weeks. Criteria for stopping the test were: significant ST depression or elevation, typical chest pain, major arrhythmias and left ventricular dysfunction. The test was considered as positive if a deterioration of basal wall motion pattern was observed: it was defined homozonally positive (the deterioration occurred in the myocardial area fed by the culprit vessel) or heterozonally positive (the deterioration occurred in a different vascular area). A coronary stenosis > 70% of vessel lumen was defined as critical. Thirty-four patients showed a negative test result. Among the 87 patients with positive test, 65 had no further wall motion deterioration from the first-induced wall motion abnormality (WMA) to peak test (Group A), whereas nine patients showed further homozonal (Group B) and 13 further heterozonal (Group C) asynergies. Sensitivity, specificity and accuracy of dobutamine stress echocardiography for multivessel disease were, respectively, 63%, 96% and 82% using the first-induced wall motion abnormality as test end-point, whilst they were 84% (P < 0.01), 93% and 89% according to the aggressive approach previously described. Dobutamine stress time of patients with multivessel disease was higher in Groups B and C (13.1 +/- 3.6 min) than in Group A (9.8 +/- 3.7 min, P < 0.01) and, finally, the mean obstruction of non-culprit vessel was higher in Group A (62.2%) than in Group C (47.4%, P < 0.05). No major complications were found. We conclude that the sensitivity of dobutamine stress echocardiography for multivessel disease following recent myocardial infarction is critically dependent on the test end-point. It may be improved by a more aggressive approach capable to identify less severe heterozonal coronary lesions.
我们的目的是验证对于急性心肌梗死后多支血管病变，更积极的方案（即如果梗死区域出现室壁运动异常但无广泛缺血或左心室功能障碍的临床或仪器标记物时，不将首次出现的室壁运动异常视为绝对终点）是否能提高药物负荷超声心动图的敏感性。121例连续患者（年龄32 - 71岁）在无并发症的心肌梗死后11.8±4.8天前瞻性接受多巴酚丁胺 - 阿托品负荷超声心动图检查（多巴酚丁胺输注至40微克/千克/分钟并额外给予阿托品1毫克），并在6周内进行冠状动脉造影。停止检查的标准为：显著的ST段压低或抬高、典型胸痛、严重心律失常和左心室功能障碍。如果观察到基础室壁运动模式恶化，则该检查被视为阳性：定义为同区域阳性（恶化发生在罪犯血管供血的心肌区域）或异区域阳性（恶化发生在不同的血管区域）。血管腔狭窄>70%被定义为严重狭窄。34例患者检查结果为阴性。在87例检查阳性的患者中，65例从首次诱发的室壁运动异常（WMA）到检查峰值没有进一步的室壁运动恶化（A组），而9例患者出现进一步的同区域（B组）和13例出现进一步的异区域（C组）运动失调。以首次诱发的室壁运动异常作为检查终点时，多巴酚丁胺负荷超声心动图对多支血管病变的敏感性、特异性和准确性分别为63%、96%和82%，而根据上述积极方案则分别为84%（P<0.01）、93%和89%。多支血管病变患者的多巴酚丁胺负荷时间在B组和C组（13.1±3.6分钟）高于A组（9.8±3.7分钟，P<0.01），最后，非罪犯血管的平均阻塞程度在A组（62.2%）高于C组（47.4%，P<0.05）。未发现严重并发症。我们得出结论，多巴酚丁胺负荷超声心动图对近期心肌梗死后多支血管病变的敏感性严重依赖于检查终点。通过更积极的方法能够识别不太严重的异区域冠状动脉病变，可以提高其敏感性。
