Chaitman B R, Stone P H, Knatterud G L, Forman S A, Sopko G, Bourassa M G, Pratt C, Rogers W J, Pepine C J, Conti C R
Division of Cardiology, Saint Louis University Health Sciences Center, Missouri 63110-0250, USA.
J Am Coll Cardiol. 1995 Sep;26(3):585-93. doi: 10.1016/0735-1097(95)00013-t.
This report from the Asymptomatic Cardiac Ischemia Pilot (ACIP) study examines differences in the magnitude of reduction of myocardial ischemia as determined by exercise treadmill testing in patients randomized to three different treatment strategies: angina-guided medical therapy, ischemia-guided medical therapy and coronary revascularization.
No prospective randomized clinical trials in patients with exercise electrocardiographic (ECG) abnormalities and asymptomatic cardiac ischemia on ambulatory ECG monitoring have compared the impact of different treatment strategies, including coronary revascularization, in terms of reducing myocardial ischemia.
The ACIP exercise protocol was used. Exercise variables measured included final exercise stage; presence of exercise-induced angina or ischemia; time to angina; time to 1-mm ST segment depression; number of exercise ECG leads with abnormalities; maximal depth of ST segment depression in any lead; sum of ST segment depression; ST/HR index; and rate-pressure product at time to angina, at time to 1-mm ST segment depression and at peak exertion.
Peak exercise time was increased by 0.5, 0.7 and 1.6 min in patients assigned to the angina-guided, ischemia-guided and coronary revascularization strategies, respectively, from the qualifying visit to the 12-week visit (p < 0.001). At the qualifying visit, the sum of exercise-induced ST segment depression was 9.4 +/- 5.0 (mean +/- SD), 9.6 +/- 4.7 and 9.9 +/- 5.5 mm (p = NS) in the three treatment strategies, respectively. At the 12-week visit, the sum of exercise-induced ST segment depression was 7.4 +/- 5.7, 6.8 +/- 5.3 and 5.6 +/- 5.6 mm (p = 0.02) in the three treatment strategies, respectively. Each treatment strategy resulted in a significant reduction in all exercise-induced variables of myocardial ischemia measured at 12 weeks.
Coronary revascularization significantly reduced the extent and frequency of exercise-induced myocardial ischemia compared with either medical strategy. The prognostic impact of these observations should be evaluated in a large-scale multicenter clinical trial.
本份来自无症状性心肌缺血试验（ACIP）研究的报告，探讨了随机接受三种不同治疗策略的患者，即心绞痛导向药物治疗、缺血导向药物治疗和冠状动脉血运重建，通过运动平板试验测定的心肌缺血减少幅度的差异。
对于动态心电图监测显示运动心电图（ECG）异常且有无症状性心肌缺血的患者，尚无前瞻性随机临床试验比较不同治疗策略（包括冠状动脉血运重建）对减少心肌缺血的影响。
采用ACIP运动方案。测量的运动变量包括最终运动阶段；运动诱发心绞痛或缺血的情况；心绞痛发作时间；ST段压低1毫米的时间；运动心电图导联异常数量；任何导联ST段压低的最大深度；ST段压低总和；ST/HR指数；以及心绞痛发作时、ST段压低1毫米时和运动峰值时的心率血压乘积。
从入选访视到12周访视，接受心绞痛导向、缺血导向和冠状动脉血运重建策略的患者，运动峰值时间分别增加了0.5、0.7和1.6分钟（p<0.001）。在入选访视时，三种治疗策略中运动诱发的ST段压低总和分别为9.4±5.0（均值±标准差）、9.6±4.7和9.9±5.5毫米（p=无显著性差异）。在12周访视时，三种治疗策略中运动诱发的ST段压低总和分别为7.4±5.7、6.8±5.3和5.6±5.6毫米（p=0.02）。每种治疗策略均使12周时测量的所有运动诱发的心肌缺血变量显著降低。
与药物治疗策略相比，冠状动脉血运重建显著降低了运动诱发的心肌缺血的程度和频率。这些观察结果的预后影响应在大规模多中心临床试验中进行评估。
