Moss A J, Goldstein R E, Hall W J, Bigger J T, Fleiss J L, Greenberg H, Bodenheimer M, Krone R J, Marcus F I, Wackers F J
University of Rochester, NY Medical Center 14642.
JAMA. 1993 May 12;269(18):2379-85.
To determine the clinical significance of silent and symptomatic myocardial ischemia detected by noninvasive testing in stable postcoronary patients.
Cohort study with a mean 23-month follow-up.
Ambulatory outpatients after recent hospitalization for an acute coronary event.
Nine hundred thirty-six patients (76% male; mean age, 58 years) who were clinically stable 1 to 6 months after hospitalization for acute myocardial infarction or unstable angina.
Noninvasive testing involved rest, ambulatory, and exercise electrocardiograms and stress thallium-201 scintigraphy.
Cox regression analysis was used to evaluate the risk (hazard ratio) of first recurrent primary events (cardiac death, nonfatal infarction, or unstable angina) or restricted events (cardiac death or nonfatal infarction) associated with ischemic noninvasive test results.
ST segment depression on the rest electrocardiogram was the only noninvasive test variable that identified a significantly increased risk (P = .05) for first recurrent primary events (hazard ratio; 95% confidence limits): rest electrocardiogram ST depression (1.5; 1.00, 2.25); ambulatory electrocardiogram ST depression (0.86; 0.49, 1.51); exercise electrocardiogram ST depression (1.13; 0.82, 1.56); and stress thallium-201 reversible defects (1.3; 0.96, 1.74). Test results were similar for first recurrent restricted events, and in patients with and without angina. Significantly increased risk (P < .05) was noted when exercise-induced ST depression occurred in patients who also had reduced exercise duration (hazard ratio, 3.4) or when reversible thallium-201 defects occurred in patients who also had increased lung uptake (hazard ratio, 2.8). Each high-risk subset made up less than 3% of the population and contained less than 6% of patients with first primary events.
Detection of silent or symptomatic myocardial ischemia by non-invasive testing in stable patients 1 to 6 months after an acute coronary event is not useful in identifying patients at increased risk for subsequent coronary events.
确定在冠状动脉疾病稳定期患者中，通过无创检测发现的无症状和有症状心肌缺血的临床意义。
进行平均为期23个月随访的队列研究。
近期因急性冠状动脉事件住院后的门诊患者。
936例患者（男性占76%；平均年龄58岁），在因急性心肌梗死或不稳定型心绞痛住院1至6个月后病情临床稳定。
无创检测包括静息、动态和运动心电图以及负荷铊-201心肌显像。
采用Cox回归分析评估与缺血性无创检测结果相关的首次复发性主要事件（心源性死亡、非致死性心肌梗死或不稳定型心绞痛）或受限事件（心源性死亡或非致死性心肌梗死）的风险（风险比）。
静息心电图ST段压低是唯一能确定首次复发性主要事件风险显著增加（P = 0.05）的无创检测变量（风险比；95%置信区间）：静息心电图ST段压低（1.5；1.00，2.25）；动态心电图ST段压低（0.86；0.49，1.51）；运动心电图ST段压低（1.13；0.82，1.56）；以及负荷铊-201可逆性缺损（1.3；0.96，1.74）。首次复发性受限事件以及有和无心绞痛患者的检测结果相似。当运动持续时间缩短的患者出现运动诱发的ST段压低（风险比，3.4）或肺摄取增加的患者出现铊-201可逆性缺损（风险比，2.8）时，风险显著增加（P < 0.05）。每个高危亚组占总体人群的比例不到3%，且首次发生主要事件的患者占比不到6%。
在急性冠状动脉事件发生1至6个月后的稳定患者中，通过无创检测发现无症状或有症状心肌缺血，对于识别后续冠状动脉事件风险增加的患者并无帮助。
