Morris C K, Morrow K, Froelicher V F, Hideg A, Hunter D, Kawaguchi T, Ribisl P M, Ueshima K, Wallis J
Department of Cardiology, Long Beach Veterans Affairs Medical Center.
Am Heart J. 1993 Jun;125(6):1717-26. doi: 10.1016/0002-8703(93)90764-z.
The objective of this report is the development of a population-specific prediction rule based on clinical and exercise test data that would estimate the risk of cardiovascular death in patients selected for cardiac catheterization. Prospective data and follow-up information were obtained from patients who underwent cardiac catheterization soon after clinical assessment and exercise testing. Males (n = 588) referred for evaluation of coronary heart disease from 1984 to 1990 were selected after exclusion of patients with significant valvular heart disease and patients with prior cardiac surgery. Half had a prior myocardial infarction and half complained of typical angina pectoris. All patients performed a treadmill test and were selected for clinical reasons to undergo coronary angiography within 3 months. Over a mean follow-up period of 2.5 years (+/- 1.4 years), there were 39 cardiovascular deaths and 45 nonfatal myocardial infarctions. The Cox proportional hazards model demonstrated the following characteristics to be statistically significant independent predictors of time until cardiovascular death: history of congestive heart failure (hazards ratio of 4), ST depression on the resting ECG (hazards ratio of 3), and a drop in systolic blood pressure below the resting value during exercise (hazards ratio of 5). Exercise-induced ST depression was not associated with either death or nonfatal myocardial infarction. A simple score based on one item of clinical information (history of congestive heart failure), a resting ECG finding (ST depression), and an exercise test response (exertional hypotension) stratified our patients for 4 years after testing from 75% with a low risk (annual cardiac mortality rate of 1%), 17% with a moderate risk (annual mortality rate of 7%), and 1% with a high risk (annual cardiac mortality rate of 12%, with a hazards ratio of 20 and 95% confidence interval from 6 to 70X). It was concluded that the variables available from the usual noninvasive workup of patients with known or suspected coronary artery disease enable prediction of risk of cardiovascular death. Three quarters of those usually undergoing cardiac catheterization can be identified by simple noninvasive variables as being at such low risk that invasive intervention is unlikely to improve prognosis.
本报告的目的是基于临床和运动试验数据制定一项针对特定人群的预测规则，以估计接受心导管检查患者的心血管死亡风险。前瞻性数据和随访信息来自于临床评估和运动试验后不久接受心导管检查的患者。选取了1984年至1990年间因冠心病接受评估的男性患者（n = 588），排除了患有严重瓣膜性心脏病的患者和曾接受心脏手术的患者。一半患者有过心肌梗死，另一半主诉典型心绞痛。所有患者均进行了平板运动试验，并因临床原因被选择在3个月内接受冠状动脉造影。在平均2.5年（±1.4年）的随访期内，有39例心血管死亡和45例非致命性心肌梗死。Cox比例风险模型显示，以下特征是心血管死亡时间的统计学显著独立预测因素：充血性心力衰竭病史（风险比为4）、静息心电图ST段压低（风险比为3）以及运动期间收缩压降至静息值以下（风险比为5）。运动诱发的ST段压低与死亡或非致命性心肌梗死均无关联。基于一项临床信息（充血性心力衰竭病史）、一项静息心电图表现（ST段压低）和一项运动试验反应（运动性低血压）的简单评分，将我们的患者在测试后4年分为低风险组（75%，年心脏死亡率为1%）、中度风险组（17%，年死亡率为7%）和高风险组（1%，年心脏死亡率为12%，风险比为20，95%置信区间为6至70）。得出的结论是，已知或疑似冠状动脉疾病患者常规无创检查中可用的变量能够预测心血管死亡风险。通常接受心导管检查的患者中有四分之三可通过简单的无创变量被识别为风险极低，以至于侵入性干预不太可能改善预后。
