Gosselink A T, Liem A L, Reiffers S, Zijlstra F
Department of Cardiology, Hospital de Weezenlanden, Zwolle, The Netherlands.
Clin Cardiol. 1998 Apr;21(4):254-60. doi: 10.1002/clc.4960210405.
Previous studies have demonstrated the prognostic value of radionuclide ventriculography at rest and exercise in patients post myocardial infarction (MI). The number of studies in patients treated with modern reperfusion techniques, including thrombolysis or primary angioplasty, however, is limited.
The aim of this study was to evaluate the prognostic significance of predischarge radionuclide ventriculography at rest and exercise in patients with acute MI treated with thrombolysis or primary angioplasty.
A total of 272 consecutive patients with acute MI who were randomized to thrombolysis or primary coronary angioplasty underwent predischarge resting and exercise radionuclide ventriculography. Left ventricular ejection fraction at rest, decrease in ejection fraction during exercise > 5 units below the resting value, angina pectoris, ST-segment depression, and exercise test ineligibility were related to subsequent cardiac events (cardiac death, nonfatal reinfarction) during follow-up.
During a mean follow-up of 30 +/- 10 months, cardiac death occurred in 11 (4%) patients and nonfatal reinfarction in 14 (5%) patients. Resting left ventricular ejection fraction was the major risk factor for cardiac death. In patients with an ejection fraction < 40%, cardiac death occurred in 16% compared with 2% in those with an ejection fraction > or = 40% (p = 0.0004). In addition, cardiac death tended to be higher in patients ineligible than in those eligible for exercise testing (11 vs. 3%, p = 0.08). None of the other exercise variables (decrease in ejection fraction during exercise > 5 units below the resting value, angina pectoris or ST-segment depression) were predictive for cardiac death. When all exercise test variables in each patient were combined and expressed as a risk score, a low risk (n = 185) and a higher risk (n = 87) group of patients could be identified, with cardiac death occurring in 1 and 10%, respectively. As the predictive accuracy of a negative test was high, radionuclide ventriculography was of particular value in identifying patients at low risk for cardiac death. Radionuclide ventriculography was not able to predict recurrent nonfatal MI.
In patients with MI treated with thrombolysis or primary angioplasty, radionuclide ventriculography may be helpful in identifying patients at low risk for subsequent cardiac death. In this respect, left ventricular ejection fraction at rest was the major determinant. Variables reflecting residual myocardial ischemia were of limited prognostic value. Identification of a large number of patients at low risk allows selective use of medical resources during follow-up in this subgroup and has significant implications for the cost effectiveness of reperfusion therapies.
先前的研究已证实静息和运动时放射性核素心室造影对心肌梗死（MI）后患者的预后价值。然而，关于接受现代再灌注技术（包括溶栓或直接血管成形术）治疗的患者的研究数量有限。
本研究的目的是评估接受溶栓或直接血管成形术治疗的急性MI患者出院前静息和运动时放射性核素心室造影的预后意义。
共有272例连续的急性MI患者被随机分为溶栓组或直接冠状动脉血管成形术组，他们在出院前接受了静息和运动放射性核素心室造影。静息时左心室射血分数、运动时射血分数下降超过静息值5个单位、心绞痛、ST段压低以及运动试验不合格与随访期间随后的心脏事件（心源性死亡、非致死性再梗死）相关。
在平均30±10个月的随访期间，11例（4%）患者发生心源性死亡，14例（5%）患者发生非致死性再梗死。静息时左心室射血分数是心源性死亡的主要危险因素。射血分数<40%的患者中心源性死亡发生率为16%，而射血分数≥40%的患者中为2%（p = 0.0004）。此外，运动试验不合格的患者心源性死亡发生率倾向于高于合格患者（11%对3%，p = 0.08）。其他运动变量（运动时射血分数下降超过静息值5个单位、心绞痛或ST段压低）均不能预测心源性死亡。当将每位患者的所有运动试验变量合并并表示为风险评分时，可以识别出低风险（n = 185）和高风险（n = 87）两组患者，心源性死亡发生率分别为1%和10%。由于阴性试验的预测准确性较高，放射性核素心室造影在识别心源性死亡低风险患者方面具有特殊价值。放射性核素心室造影无法预测复发性非致死性MI。
在接受溶栓或直接血管成形术治疗的MI患者中，放射性核素心室造影可能有助于识别随后心源性死亡低风险的患者。在这方面，静息时左心室射血分数是主要决定因素。反映残余心肌缺血的变量预后价值有限。识别出大量低风险患者可在该亚组随访期间选择性使用医疗资源，这对再灌注治疗的成本效益具有重要意义。
