Shaw L J, Hachamovitch R, Peterson E D, Lewin H C, Iskandrian A E, Miller D D, Berman D S
Emory Center for Outcomes Research, Atlanta, GA 30322, USA.
J Gen Intern Med. 1999 Jan;14(1):1-9. doi: 10.1046/j.1525-1497.1999.00273.x.
To develop a hierarchical approach to cardiac risk stratification after treadmill testing.
Clinical and treadmill test data were used to identify a patient population that may be candidates for further risk stratification with stress tomographic myocardial perfusion imaging. A prospective series of 3, 620 medically treated patients (42% female, mean age 63 years) with a 2.5% mortality was identified (follow-up 2.5 +/- SD 1.5 years).
A Cox proportional hazards model was used to estimate a patient's likelihood of cardiac death. Kaplan-Meier survival curves were used to estimate time to cardiac death by nuclear test results. Annual rates of cardiac death were 0. 4% (n = 921), 1% (n = 2,498), and 1% (n = 201) for patients with low, intermediate, and high Duke treadmill scores (DTS). For patients with an intermediate DTS, multivariate estimators of cardiac death included the number of ischemic vascular territories (relative risk per defect 1.4, p =.01), the number of infarcted vascular territories (relative risk per defect 2.4, p =.00001), and the DTS (relative risk per unit 0.97, p =.00001), following adjustment for a patient's pretest risk of coronary disease. For patients with an intermediate DTS, the presence of no, one or two, and three vascular territories with defects was associated with annual rates of cardiac death of 0.5%, 1.4%, and 2.5%, respectively (p <.0001). Kaplan-Meier survival curves exhibited a statistically worsening survival for patients with defects by 1 year after treadmill exercise.
For symptomatic patients with an intermediate treadmill test score, the exercise myocardial perfusion scan may be used to stratify their risk of cardiac death over 3 years of follow-up. Patient management may be efficiently guided by further outcome assessment, with an exercise nuclear scan for patients whose treadmill test score is intermediate.
制定一种在平板运动试验后进行心脏风险分层的分级方法。
临床和平板运动试验数据用于确定可能适合通过负荷断层心肌灌注成像进行进一步风险分层的患者群体。确定了一个前瞻性队列，包括3620例接受药物治疗的患者（42%为女性，平均年龄63岁），死亡率为2.5%（随访2.5±标准差1.5年）。
采用Cox比例风险模型估计患者心脏死亡的可能性。Kaplan-Meier生存曲线用于根据核试验结果估计心脏死亡时间。杜克平板运动评分（DTS）低、中、高的患者心脏死亡年发生率分别为0.4%（n = 921）、1%（n = 2498）和1%（n = 201）。对于DTS中等的患者，在调整患者冠心病的预测试风险后，心脏死亡的多变量估计因素包括缺血血管区域数量（每个缺损的相对风险为1.4，p = 0.01）、梗死血管区域数量（每个缺损的相对风险为2.4，p = 0.00001）和DTS（每单位的相对风险为0.97，p = 0.00001）。对于DTS中等的患者，无、一或两个、三个有缺损的血管区域的存在分别与心脏死亡年发生率0.5%、1.4%和2.5%相关（p < 0.0001）。Kaplan-Meier生存曲线显示，平板运动试验后1年有缺损的患者生存情况在统计学上恶化。
对于平板运动试验评分中等的有症状患者，运动心肌灌注扫描可用于在3年随访期间对其心脏死亡风险进行分层。通过进一步的结局评估，可有效地指导患者管理，对于平板运动试验评分中等的患者进行运动核扫描。
