Mattera J A, Arain S A, Sinusas A J, Finta L, Wackers F J
Center for Outcomes Research and Evaluation, Yale New Haven Hospital, New Haven, Conn, USA.
J Nucl Cardiol. 1998 Sep-Oct;5(5):498-506. doi: 10.1016/s1071-3581(98)90181-7.
It has been suggested that in patients with a normal resting electrocardiogram (ECG), exercise radionuclide myocardial perfusion imaging (MPI) does not add significant incremental diagnostic information to exercise ECG.
Of 840 consecutive patients referred for physical exercise MPI, 313 (37%) had normal resting ECGs. There were 189 men and 124 women with a mean age of 54+/-11.9 years. Exercise MPI was performed with either TI-201 or 99mTc-labeled sestamibi. Overall concordance between exercise ECG result and MPI result was 79% (kappa agreement = .54). One hundred eighty-four patients had normal exercise ECG; 181 (98.4%) of these also had normal exercise MPI. In 271 patients with low (< or =20%) to intermediate (21% to 70%) pre-exercise likelihood of coronary artery disease (CAD), concordance between normal exercise ECG and normal MPI was 100%. In the high likelihood (> or =71%) group 3 (15 %) patients with normal exercise ECG had abnormal exercise MPI. Of 129 patients with abnormal exercise ECG, 67 (52%) patients also had abnormal MPI, but 62 (48%) patients had normal MPI. Complete follow-up was obtained in 89% of patients at 9 months. Only 1 hard cardiac event occurred: nonfatal myocardial infarction. Twenty-one (8%) patients had subsequent coronary revascularization or admission with unstable angina. Although both abnormal stress ECG and abnormal exercise MPI were significantly (P < .0001) associated with hard and "soft" events, the association of abnormal exercise MPI was significantly stronger. Because all patients with a low and intermediate likelihood of CAD who had normal exercise ECG also had normal exercise MPI, we propose a stepwise diagnostic testing strategy whereby exercise MPI imaging is performed only in patients with a low to intermediate likelihood of CAD when the exercise ECG is abnormal. When the exercise ECG is performed first, and exercise MPI is performed only when the exercise ECG is abnormal, substantial (38%) cost savings can be achieved. In patients with a high likelihood of CAD, the exercise ECG may be falsely negative, and exercise MPI is preferred.
In patients with normal resting ECGs a stepwise diagnostic strategy can reduce costs of exercise testing without compromising diagnostic yield when pretest likelihood of coronary artery disease is taken into consideration.
有人提出，对于静息心电图（ECG）正常的患者，运动放射性核素心肌灌注显像（MPI）并未给运动心电图增加显著的额外诊断信息。
在连续840例因进行运动MPI而就诊的患者中，313例（37%）静息ECG正常。其中男性189例，女性124例，平均年龄54±11.9岁。运动MPI采用铊-201或锝-99m标记的甲氧基异丁基异腈进行。运动心电图结果与MPI结果的总体一致性为79%（kappa一致性=.54）。184例患者运动心电图正常；其中181例（98.4%）运动MPI也正常。在271例运动前冠心病（CAD）可能性低（≤20%）至中度（21%至70%）的患者中，运动心电图正常与运动MPI正常之间的一致性为100%。在高可能性（≥71%）组中，3例（15%）运动心电图正常的患者运动MPI异常。在129例运动心电图异常的患者中，67例（52%）患者MPI也异常，但62例（48%）患者MPI正常。89%的患者在9个月时获得了完整随访。仅发生1例严重心脏事件：非致命性心肌梗死。21例（8%）患者随后进行了冠状动脉血运重建或因不稳定型心绞痛入院。虽然运动应激心电图异常和运动MPI异常均与严重和“轻微”事件显著相关（P<.0001），但运动MPI异常的相关性显著更强。由于所有CAD可能性低和中度且运动心电图正常的患者运动MPI也正常，我们提出一种逐步诊断测试策略，即仅在运动心电图异常的CAD可能性低至中度的患者中进行运动MPI显像。当首先进行运动心电图检查，且仅在运动心电图异常时进行运动MPI检查时，可节省大量（38%）费用。在CAD可能性高的患者中，运动心电图可能出现假阴性，因此首选运动MPI。
对于静息心电图正常的患者，考虑到冠状动脉疾病的预检可能性时，逐步诊断策略可降低运动测试成本，而不影响诊断率。
