Minardi G, Boccardi L, Di Segni M, Pucci E, Tubaro M, Natale E, Milazzotto F, Loschiavo P, Lioy E, Biffani G
Dipartimento di Cardiologia, Ospedale S. Camillo, Roma.
G Ital Cardiol. 1993 Dec;23(12):1177-85.
The aim of this study was to examine the ability of Dipyridamole Echocardiography Test (DET)--performed early after an acute myocardial infarction (AMI)--to assess: a) the presence of induced ischemia and its relation with coronary artery stenoses; b) the presence of myocardial viability and the comparison with late wall motion; c) the appearance of cardiac events during hospitalization and in the following period.
Ninety-five patients with AMI, subjected to thrombolytic therapy and without complications, underwent a DET on the 4th-5th day. All had a coronary angiography on the 8th-10th day; stenoses were deemed significative when > or = 70%. DET was carried out after drug discontinuance and following standard protocol; parietal kinesis was analyzed according to a 14 segment model. The myocardium was deemed viable when an improvement of a basal dyskinesis was noted; ischemia was considered when a new asynergy appeared or a basal dyskinesis worsened or enlarged; a wall motion score index (WMSI) was calculated. All 95 pts. had a clinical follow-up at 12 +/- 6 months (3-18); 62 pts. had a late echocardiographic examination at 6 +/- 3 months (3-15).
Induced ischemia appeared in 59/95 pts. (62%): in 6/14 pts. (42%) without significative stenoses, in 29/49 pts. (59%) with a single vessel disease, and in 24/32 pts. (75%) with multivessel disease. In identifying multivessel disease, DET sensibility (SE) was 75% and specificity (SP) was 95-97%. In single or no vessel disease WMSI changed from 1.42 to 1.49 (p < 0.0001); in multivessel disease WMSI changed from 1.52 to 1.69 (p < 0.0001). As regards the assessment of diseased vessel(s), DET showed little accuracy when dyskinesis appeared in the basal segments of the inferior and lateral wall or in the mid-apical segments of the anterior and lateral wall; DET properly identified the culprit vessel when dyskinesis appeared in the remaining segments. Myocardial viability was noted in 26% of dyskinetic segments. In single or no vessel disease WMSI changed from 1.41 (basal--> B) to 1.35 (viability phase--> V) and was found 1.31 at the late echocardiography (L): p < 0.0001 between B and V, and between B and L. In multivessel disease WMSI changed from 1.5 (B) to 1.47 (V) and to 1.5 (L): p < 0.05 between B and V, NS between B and L. In comparison with late echocardiography, DET SE was 70%, SP 99%, positive predictive value (PPV) 97%, negative predictive value (NPV) 86%. As regards the prognostic value about cardiac events, DET SE was 80% and NPV was 78%; about only major cardiac events, the respective values are 91% and 97%.
DET performed early after an AMI allows a better prognostic assessment, as it provides information about: a) the place and the severity of coronary artery stenoses; b) the presence and the extension of induced ischemia and of myocardial viability; c) the risk of subsequent cardiac events.
本研究旨在探讨急性心肌梗死（AMI）后早期进行的双嘧达莫超声心动图试验（DET）的能力，以评估：a）诱发缺血的存在及其与冠状动脉狭窄的关系；b）心肌存活的存在以及与晚期室壁运动的比较；c）住院期间及随后时期心脏事件的发生情况。
95例接受溶栓治疗且无并发症的AMI患者在第4 - 5天接受了DET。所有患者在第8 - 10天进行了冠状动脉造影；当狭窄≥70%时被认为具有显著性。DET在停药后按照标准方案进行；根据14节段模型分析壁运动。当观察到基础运动障碍有所改善时，心肌被认为存活；当出现新的运动失调或基础运动障碍加重或扩大时，考虑存在缺血；计算壁运动评分指数（WMSI）。所有95例患者在12±6个月（3 - 18个月）进行了临床随访；62例患者在6±3个月（3 - 15个月）进行了晚期超声心动图检查。
59/95例患者（62%）出现诱发缺血：14例无显著性狭窄患者中有6例（42%），49例单支血管病变患者中有29例（59%），32例多支血管病变患者中有24例（75%）。在识别多支血管病变时，DET的敏感性（SE）为75%，特异性（SP）为95 - 97%。在单支或无血管病变中，WMSI从1.42变为1.49（p < 0.0001）；在多支血管病变中，WMSI从1.52变为1.69（p < 0.0001）。关于病变血管的评估，当在下壁和侧壁的基底节段或前壁和侧壁的中尖段出现运动障碍时，DET的准确性较低；当在其余节段出现运动障碍时，DET能正确识别罪犯血管。26%的运动障碍节段存在心肌存活。在单支或无血管病变中，WMSI从1.41（基础期→B）变为1.35（存活期→V），晚期超声心动图（L）时为1.31：B与V之间以及B与L之间p < 0.0001。在多支血管病变中，WMSI从1.5（B）变为1.47（V）再变为1.5（L）：B与V之间p < 0.05，B与L之间无显著性差异。与晚期超声心动图相比，DET的SE为70%，SP为99%，阳性预测值（PPV）为97%，阴性预测值（NPV）为86%。关于心脏事件的预后价值，DET的SE为80%，NPV为78%；仅关于主要心脏事件，相应值分别为91%和97%。
AMI后早期进行的DET可提供关于：a）冠状动脉狭窄的部位和严重程度；b）诱发缺血和心肌存活的存在及范围；c）后续心脏事件风险的信息，从而实现更好的预后评估。
