Poldermans D, Arnese M, Fioretti P M, Salustri A, Boersma E, Thomson I R, Roelandt J R, van Urk H
Thoraxcentre, Erasmus University, Rotterdam, The Netherlands.
J Am Coll Cardiol. 1995 Sep;26(3):648-53. doi: 10.1016/0735-1097(95)00240-5.
This study sought to optimize preoperative cardiac risk stratification in a large group of consecutive candidates for vascular surgery by combining clinical risk assessment and semiquantitative dobutamine-atropine stress echocardiography.
Dobutamine-atropine stress echocardiography has been used for the prediction of perioperative cardiac risk in a small group of patients scheduled for elective major vascular surgery on the basis of the presence or absence of stress-induced regional left ventricular wall motion abnormalities.
Clinical risk assessment and dobutamine-atropine stress echocardiography were performed in 302 consecutive patients presenting for major vascular surgery. The extent and severity of stress wall motion abnormalities and the heart rate at which they occurred, in addition to the presence of wall motion abnormalities at rest, were assessed.
The absence of clinical risk factors (angina, diabetes, Q waves on the electrocardiogram, symptomatic ventricular tachyarrhythmias, age > 70 years) identified a low risk group of 100 patients with a 1% cardiac event rate (unstable angina). Dobutamine-atropine stress echocardiographic findings were positive in 72 patients. Twenty-seven patients had a perioperative cardiac event (cardiac death in 5, nonfatal infarction in 12, unstable angina pectoris in 10); all 27 patients had positive stress test results (positive predictive value 38%, negative predictive value 100%). The semiquantitative assessment of the extent and severity of ischemia did not provide additional prognostic information in patients with positive test results. In contrast, the heart rate at which ischemia occurred defined a high risk group with a low ischemic threshold (38 patients with 20 events [53%]) and an intermediate risk group with a high ischemic threshold (34 patients with 7 events [21%]). All 5 patients with a fatal outcome and 8 of 12 with a nonfatal myocardial infarction were in the high risk group with a low ischemic threshold.
Clinical variables identify 33% of patients at very low risk for perioperative complications of vascular surgery in whom further testing is redundant. In all other candidates, dobutamine-atropine stress echocardiography is a powerful tool that identifies those patients at intermediate risk and a small group at very high risk. Risk stratification with a combination of clinical assessment and pharmacologic stress echocardiography has the potential to facilitate clinical decision making and conserve resources.
本研究旨在通过结合临床风险评估和半定量多巴酚丁胺 - 阿托品负荷超声心动图，优化一大组连续的血管手术候选患者的术前心脏风险分层。
多巴酚丁胺 - 阿托品负荷超声心动图已用于一小部分计划进行择期大血管手术患者的围手术期心脏风险预测，其依据是是否存在应激诱导的局部左心室壁运动异常。
对302例连续进行大血管手术的患者进行临床风险评估和多巴酚丁胺 - 阿托品负荷超声心动图检查。评估应激时壁运动异常的范围和严重程度、其发生时的心率，以及静息时壁运动异常的情况。
无临床风险因素（心绞痛、糖尿病、心电图上的Q波、有症状的室性心律失常、年龄>70岁）的患者确定为低风险组，共100例，心脏事件发生率为1%（不稳定型心绞痛）。多巴酚丁胺 - 阿托品负荷超声心动图检查结果阳性的患者有72例。27例患者发生围手术期心脏事件（5例心脏死亡，12例非致命性心肌梗死，10例不稳定型心绞痛）；所有27例患者的负荷试验结果均为阳性（阳性预测值38%，阴性预测值100%）。对于负荷试验结果阳性的患者，缺血范围和严重程度的半定量评估未提供额外的预后信息。相比之下，缺血发生时的心率确定了一个低缺血阈值的高风险组（38例患者，20例事件[53%]）和一个高缺血阈值的中风险组（34例患者，7例事件[21%]）。所有5例有致命结局的患者和12例非致命性心肌梗死患者中的8例属于低缺血阈值的高风险组。
临床变量可识别出33%的血管手术围手术期并发症风险极低的患者，对这些患者进一步检查是多余的。在所有其他候选患者中，多巴酚丁胺 - 阿托品负荷超声心动图是一种强大的工具，可识别出中度风险患者和一小部分极高风险患者。结合临床评估和药物负荷超声心动图进行风险分层有可能促进临床决策并节省资源。
