Smart S C, Dionisopoulos P N, Knickelbine T A, Schuchard T, Sagar K B
Medical College of Wisconsin, Division of Cardiovascular Medicine, Milwaukee, USA.
J Am Coll Cardiol. 1999 Feb;33(2):512-21. doi: 10.1016/s0735-1097(98)00594-4.
To assess the prognostic value of sustained improvement, scar and inducible ischemia with or without viability in patients with chronic left ventricular dysfunction (LVD).
Dobutamine-atropine stress echocardiography (DASE) accurately detects scar, reversible dysfunction and the extent of coronary artery disease in LVD.
Three hundred fifty consecutive patients (age 62+/-13 years, mean+/-SD, 215 men/135 women) with moderate to severe LVD (LVEF < 40%, mean 30+/-8%) underwent DASE and were followed for > or =18 months. Dobutamine-atropine stress echocardiographic findings were classified according to sustained improvement in all vascular territories, scar, inducible ischemia (worsening wall motion at peak dose only or biphasic responses) and their extent.
Sustained improvement occurred in 83 patients (24%), scar alone in 99 (28%) and inducible ischemia in 168 (48%, with biphasic responses in 104). Ischemia was induced in all vascular territories in 26 patients. Patients with sustained improvement or scar alone were treated medically, whereas 46% (78/168) with inducible ischemia were revascularized (coronary bypass surgery, n = 67 or angioplasty, n = 11). There were 76 hard events including cardiac death in 59, nonfatal myocardial infarction in 11, and resuscitated sudden death in 6. Hard events were rare in sustained improvement (5%, 4/83), uncommon in scar (13%, 13/99) and common (p < 0.01) in medically treated patients with inducible ischemia (59%, 53/90). Cardiac deaths were especially common (p < 0.01) in patients with biphasic responses (55%, 28/51). Inducible ischemia independently predicted hard events (chi2 = 75.35, p < 0.001) along with reduced LVEF at peak dose (chi2 = 8.38, p = 0.004). Hard cardiac events were uncommon (8%, 6/78, p < 0.001) in patients with inducible ischemia who underwent early revascularization.
Inducible ischemia during DASE was the major determinant of outcome in LVD and independent of clinical data and left ventricular function. Improved wall thickening alone and scar alone predicted good outcome. Survival of patients with inducible ischemia was better after revascularization.
评估慢性左心室功能不全（LVD）患者持续改善、瘢痕以及伴有或不伴有存活心肌的可诱导性心肌缺血的预后价值。
多巴酚丁胺 - 阿托品负荷超声心动图（DASE）可准确检测LVD患者的瘢痕、可逆性功能障碍及冠状动脉疾病的范围。
连续纳入350例中重度LVD患者（年龄62±13岁，平均±标准差，男性215例/女性135例），左心室射血分数（LVEF）<40%，平均为30±8%，均接受DASE检查，并随访≥18个月。根据所有血管区域的持续改善情况、瘢痕、可诱导性心肌缺血（仅在峰值剂量时室壁运动恶化或双相反应）及其范围对多巴酚丁胺 - 阿托品负荷超声心动图检查结果进行分类。
83例患者（24%）出现持续改善，99例（28%）仅有瘢痕，168例（48%）出现可诱导性心肌缺血（其中104例为双相反应）。26例患者所有血管区域均诱发了心肌缺血。持续改善或仅有瘢痕的患者接受药物治疗，而168例有可诱导性心肌缺血的患者中46%（78/168）接受了血运重建治疗（冠状动脉搭桥手术，67例；血管成形术，11例）。发生了76例严重事件，包括59例心源性死亡、11例非致命性心肌梗死和6例复苏成功的心脏骤停。持续改善的患者中严重事件罕见（5%，4/83），仅有瘢痕的患者中不常见（13%，13/99），而接受药物治疗的有可诱导性心肌缺血的患者中则很常见（p<0.01，59%，53/90）。双相反应患者的心源性死亡尤为常见（p<0.01，55%，28/51）。可诱导性心肌缺血独立预测严重事件（χ²=75.35，p<0.001），同时峰值剂量时LVEF降低也可预测（χ²=8.38，p=0.004）。早期接受血运重建治疗的有可诱导性心肌缺血的患者中严重心脏事件不常见（8%，6/78，p<0.001）。
DASE期间的可诱导性心肌缺血是LVD患者预后的主要决定因素，且独立于临床资料和左心室功能。单纯室壁增厚改善和仅有瘢痕预示着良好的预后。有可诱导性心肌缺血的患者血运重建后生存率更高。
