Bugiardini R, Borghi A, Pozzati A, Ruggeri A, Puddu P, Maseri A
Institute of Patologia Speciale Medica, University of Bologna, Italy.
J Am Coll Cardiol. 1995 Mar 1;25(3):597-604. doi: 10.1016/0735-1097(94)00439-W.
This study was undertaken to compare the relative power of the severity of angina versus that of any other clinical, electrocardiographic (ECG) and angiographic findings in predicting the risk of subsequent in-hospital coronary events in patients admitted to the coronary care unit for treatment of unstable angina.
The presence or absence of chest pain has traditionally been used to guide management and therapy of unstable angina. However, recent studies raised the possibility that the cumulative duration of ischemia may be an additional index of prognosis.
We studied 104 consecutive patients admitted to the coronary care unit because of unstable angina. Diaries of symptoms were accurately kept. All patients underwent Holter ambulatory ECG monitoring during the 1st 24 h and angiography within 1 week of admission.
During the hospital stay, 41 patients (group 1) had subsequent coronary events; the remaining 63 patients (group 2) had a good clinical outcome. Recurrence of chest pain after admission was observed in 76% of patients: 36 of the 41 group 1 patients (sensitivity 88%) and 43 of the 63 group 2 patients (specificity 32%). Anginal scores (frequency and persistence of pain, duration of each single episode and pain-free interval) showed high specificity but low sensitivity for detecting evolution toward subsequent coronary events. On Holter monitoring, the duration/24 h of the total number of ischemic episodes was consistently greater in group 1 than in group 2. A cumulative duration of ischemia > or = 60 min/24 h was observed in 34 of the 41 group 1 patients (sensitivity 83%) but in only 16 of the 63 group 2 patients (specificity 75%). High risk coronary artery lesions (left main coronary artery disease or complex stenosis) were detected in 36 of the 41 group 1 patients and in 26 of the 63 group 2 patients.
Transient myocardial ischemia detected by Holter monitoring, but not chest pain, is the best predictor of unfavorable short-term clinical outcome. The decision to perform early angiography and revascularization cannot be based on symptoms alone.
本研究旨在比较心绞痛严重程度与其他任何临床、心电图（ECG）及血管造影结果在预测因不稳定型心绞痛入住冠心病监护病房患者后续住院期间发生冠状动脉事件风险方面的相对预测能力。
传统上，胸痛的有无一直被用于指导不稳定型心绞痛的管理和治疗。然而，最近的研究提出，缺血累积持续时间可能是一个额外的预后指标。
我们研究了104例因不稳定型心绞痛入住冠心病监护病房的连续患者。准确记录症状日记。所有患者在入院后的头24小时内接受动态心电图监测，并在入院1周内进行血管造影。
住院期间，41例患者（第1组）发生了后续冠状动脉事件；其余63例患者（第2组）临床结局良好。76%的患者入院后出现胸痛复发：41例第1组患者中有36例（敏感性88%），63例第2组患者中有43例（特异性32%）。心绞痛评分（疼痛频率和持续时间、单次发作持续时间和无疼痛间隔）在检测后续冠状动脉事件进展方面显示出高特异性但低敏感性。在动态心电图监测中，第1组缺血发作总数的持续时间/24小时始终高于第2组。41例第1组患者中有34例观察到缺血累积持续时间≥60分钟/24小时（敏感性83%），但63例第2组患者中只有16例（特异性75%）。41例第1组患者中有36例检测到高危冠状动脉病变（左主干冠状动脉疾病或复杂狭窄），63例第2组患者中有26例。
动态心电图监测检测到的短暂性心肌缺血而非胸痛是不良短期临床结局的最佳预测指标。早期进行血管造影和血运重建的决策不能仅基于症状。
