Azpitarte J, Navarrete A, Sánchez Ramos J
Servicio de Cardiología, Hospital Universitario Virgen de las Nieves, Granada.
Rev Esp Cardiol. 1998 Jul;51(7):533-40. doi: 10.1016/s0300-8932(98)74786-4.
The evaluation of risk after myocardial infarction accomplishes two objectives: a) selecting patients with high-risk for coronary angiography and revascularization, and b) identifying low-risk patients to avoid unnecessary laboratory investigation and revascularization procedures. Currently, patients eligible for exercise test are those with no evidence of heart failure or angina, and with a preserved left ventricular function. Overall prognosis for such patients, especially if they were thrombolyzed, is very good. In this setting, in contrast to that pointed out in previous reports, the positive predictive value of exercise electrocardiography is very low (i.e., a patient with S-T depression has a probability of cardiac death in the ensuing year of only 4% vs 2% if the test is negative). This suggests that a routine postinfarction exercise test is inefficient from a prognostic point of view. However, a recent study has shown that thrombolyzed patients with a positive response to the exercise test, have a significantly lower rate of reinfarction and unstable angina when they undergo myocardial revascularization. Mortality rate, as it was low in the study population, was unchanged by the use of revascularization procedures. We conclude that, in spite of the limitations pointed out, there are at least two reasons to continue performing exercise tests in all uncomplicated infarctions: a) a negative test, due to its high negative predictive value for adverse events, reassures the patient and his family and prompts an early discharge, and b) some patients, despite an uncomplicated in-hospital evolution, have a "strong" positive response that suggests multivessel disease and a possible benefit from myocardial revascularization.
a）选择冠状动脉造影和血运重建高风险患者，b）识别低风险患者以避免不必要的实验室检查和血运重建程序。目前，适合运动试验的患者是那些无心力衰竭或心绞痛证据且左心室功能保留的患者。这类患者的总体预后非常好，尤其是那些接受过溶栓治疗的患者。在这种情况下，与之前报告指出的情况相反，运动心电图的阳性预测值非常低（即，出现ST段压低的患者在随后一年中心脏死亡的概率仅为4%，而试验阴性者为2%）。这表明从预后角度来看，常规的梗死后运动试验效率低下。然而，最近一项研究表明，运动试验呈阳性反应的溶栓患者在接受心肌血运重建时，再梗死和不稳定型心绞痛的发生率显著降低。由于研究人群的死亡率较低，血运重建程序的使用并未改变死亡率。我们得出结论，尽管存在上述局限性，但在所有无并发症的梗死患者中继续进行运动试验至少有两个原因：a）试验阴性因其对不良事件的高阴性预测值，可使患者及其家属安心并促使早期出院，b）一些患者尽管住院期间病情无并发症，但有“强烈”的阳性反应，提示多支血管病变且可能从心肌血运重建中获益。
