Mickley H, Nielsen J R, Berning J, Junker A, Møller M
Department of Cardiology, Odense University Hospital, Denmark.
Br Heart J. 1995 Apr;73(4):320-6. doi: 10.1136/hrt.73.4.320.
To assess the five year prognostic significance of transient myocardial ischaemia on ambulatory monitoring after a first acute myocardial infarction, and to compare the diagnostic and long term prognostic value of ambulatory ST segment monitoring, maximal exercise testing, and echocardiography in patients with documented ischaemic heart disease.
Prospective study.
Cardiology department of a teaching hospital.
123 consecutive men aged under 70 who were able to perform predischarge maximal exercise testing.
Echocardiography two days before discharge (left ventricular ejection fraction), maximal bicycle ergometric testing one day before discharge (ST segment depression, angina, blood pressure, heart rate), and ambulatory ST segment monitoring (transient myocardial ischaemia) started at hospital discharge a mean of 11 (SD 5) days after infarction.
Relation of ambulatory ST segment depression, exercise test variables, and left ventricular ejection fraction to subsequent objective (cardiac death or myocardial infarction) or subjective (need for coronary revascularisation) events.
23 of the 123 patients had episodes of transient ST segment depression, of which 98% were silent. Over a mean of 5 (range 4 to 6) years of follow up, patients with ambulatory ischaemia were no more likely to have objective end points than patients without ischaemic episodes. If, however, subjective events were included an association between transient ST segment depression and an adverse long term outcome was found (Kaplan-Meier analysis; P = 0.004). The presence of exercise induced angina identified a similar proportion of patients with a poor prognosis (Kaplan-Meier analysis; P < 0.004). Both exertional angina and ambulatory ST segment depression had high specificity but poor sensitivity. The presence of exercise induced ST segment depression was of no value in predicting combined cardiac events. Indeed, patients without exertional ST segment depression were at increased risk of future objective end points (Kaplan-Meier analysis; P < 0.0045). These findings may be explained in part by a higher prevalence of left ventricular dysfunction in patients without ischaemic changes in the exercise electrocardiogram (P < 0.05).
There seem to be limited reasons to perform ambulatory ST segment monitoring in survivors of a first myocardial infarction who can perform exercise tests before discharge. Patients at high risk of future myocardial infarction or death from cardiac causes are not identified. Ambulatory monitoring and exertional angina distinguish a small subset of patients who will develop severe angina pectoris demanding coronary revascularisation during follow up. Patients without exercise induced ST segment depression comprise a high risk subgroup in terms of subsequent objective end points. The role of ambulatory ST segment monitoring performed in unselected patients immediately after infarction when risk is maximal remains to be clarified.
评估首次急性心肌梗死后动态监测中短暂性心肌缺血的五年预后意义，并比较动态ST段监测、最大运动试验和超声心动图在已确诊缺血性心脏病患者中的诊断及长期预后价值。
前瞻性研究。
一家教学医院的心脏病科。
123名年龄在70岁以下、能够在出院前进行最大运动试验的连续男性患者。
出院前两天进行超声心动图检查（左心室射血分数），出院前一天进行最大运动负荷试验（ST段压低、心绞痛、血压、心率），并在出院后平均11（标准差5）天开始进行动态ST段监测（短暂性心肌缺血）。
动态ST段压低、运动试验变量和左心室射血分数与随后的客观（心源性死亡或心肌梗死）或主观（冠状动脉血运重建需求）事件的关系。
123名患者中有23名出现短暂性ST段压低发作，其中98%为无症状性发作。在平均5（范围4至6）年的随访中，有动态缺血的患者与无缺血发作的患者相比，发生客观终点事件的可能性并无更高。然而，如果纳入主观事件，则发现短暂性ST段压低与不良长期预后之间存在关联（Kaplan-Meier分析；P = 0.004）。运动诱发心绞痛的存在确定了类似比例的预后不良患者（Kaplan-Meier分析；P < 0.004）。劳力性心绞痛和动态ST段压低均具有高特异性但低敏感性。运动诱发的ST段压低对预测合并心脏事件无价值。事实上，无劳力性ST段压低的患者未来发生客观终点事件的风险增加（Kaplan-Meier分析；P < 0.0045）。这些发现部分可能是由于运动心电图无缺血改变的患者中左心室功能障碍的患病率较高（P < 0.05）。
对于在出院前能够进行运动试验的首次心肌梗死幸存者，进行动态ST段监测的理由似乎有限。未识别出未来有心肌梗死或心源性死亡高风险的患者。动态监测和劳力性心绞痛可区分一小部分在随访期间将发生严重心绞痛并需要冠状动脉血运重建的患者。就随后的客观终点而言，无运动诱发ST段压低的患者构成一个高风险亚组。在梗死风险最大时立即对未选择的患者进行动态ST段监测的作用仍有待阐明。
