Is 'silent' myocardial ischemia really as severe as symptomatic ischemia? The analytical effect of patient selection biases.
Is 'silent' myocardial ischemia really as severe as symptomatic ischemia? The analytical effect of patient selection biases.
复制标题
“无症状”心肌缺血真的和症状性缺血一样严重吗？
DOI：
10.1161/01.cir.89.5.1958
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发表时间：
1994
期刊：
影响因子：
37.8
通讯作者：
A. Rozanski
中科院分区：
文献类型：
--
作者：
J. Klein;S. Chao;D. Berman;A. Rozanski
背景
运动性胸痛的临床意义仍然存在争议，这反映在医学文献中的临床结果明显不一致。因此，我们开展了一项前瞻性研究，以比较无症状性与症状性缺血的功能意义，并评估患者选择偏倚是否影响该分析。
方法和结果
我们评估了117例（平均年龄63 ± 9岁）在平板运动试验中出现缺血性ST段压低的患者。每例患者在运动后进行Tl-201心肌灌注单光子发射计算机断层扫描（SPECT），随后进行24小时动态心电图监测。将患者分为无症状组和有症状组，并在负荷试验期间比较血流动力学、运动和动态心电图以及铊异常的程度。随着患者人群越来越受限制，重复分析。与无症状患者相比，运动时胸痛患者运动持续时间较短（P < .009），降低峰值心率（P = 0.009）和双产品（P = .005），ST段压低的心率阈值较低（P <0.05），动态ST段压低发作次数较多05）、在T1 -201 SPECT期间缺血异常的较高频率（P = 0.02）和较高的总T1可逆性评分（P = 0.002）。随着人群限制的增加，无症状队列与有症状队列之间差异的相对幅度减小，而两个队列中缺血性异常的绝对幅度逐渐增加。例如，在运动和动态ECG均具有局部缺血的受限组中，50%的沉默队列在T1 SPECT上具有严重的局部缺血（五个或更多个可逆缺陷），并且超过三分之一的人表现出运动后短暂左心室扩张的不祥发现。
结论
当在相对“广谱”的冠状动脉疾病人群中进行分析时，胸痛的诱导与更多的功能异常相关;相反，当胸痛的分析仅限于具有更大的先验可能性表现出诱导性缺血的冠状动脉疾病人群时，胸痛往往失去其作为临床测试参数的明显价值。这些发现可能有助于解决以前的一些不一致的文献报道。
BACKGROUND
The clinical significance of exercise-induced chest pain remains controversial, as reflected by sharply discordant clinical results within the medical literature. Thus, we developed a prospective study to compare the functional significance of silent versus symptomatic ischemia and to evaluate whether patient selection biases influence this analysis.
METHODS AND RESULTS
We evaluated 117 patients (mean age, 63 +/- 9 years) with ischemic ST-segment depression during treadmill testing. Each patient underwent Tl-201 myocardial perfusion single-photon emission computed tomography (SPECT) after exercise followed by 24-ambulatory ECG monitoring. Patients were divided into silent versus symptomatic cohorts and were compared for the degree of hemodynamic, exercise and ambulatory ECG, and thallium abnormalities during stress testing. Analyses were repeated as the patient population became increasingly restricted. Compared with the silent patients, patients with chest pain during exercise had a shorter exercise duration (P < .009), lower peak heart rate (P = .009) and double product (P = .005), lower heart rate threshold for ST depression (P < .05), more episodes of ambulatory ST-segment depression (P < .05), a higher frequency of ischemia abnormalities during Tl-201 SPECT (P = .02), and higher summed Tl reversibility scores (P = .002). As the population became increasingly restricted, the relative magnitude of differences in silent versus symptomatic cohorts diminished, whereas the absolute magnitude of ischemic abnormalities progressively increased in both cohorts. For example, within the restricted group having ischemia on both exercise and ambulatory ECG, 50% of the silent cohort had severe ischemia on Tl SPECT (five or more reversible defects) and more than one third demonstrated the ominous finding of transient left ventricular dilation after exercise.
CONCLUSIONS
The induction of chest pain is associated with substantially more functional abnormalities when it is analyzed in a relatively "broad-spectrum" coronary artery disease population; by contrast, chest pain tends to lose its apparent value as a clinical test parameter when its analysis is restricted to coronary artery disease populations with a greater a priori likelihood of manifesting inducible ischemia. These findings may help resolve some of the previous discordant literature reports.
测试的目的是否应该影响其解释？
影响因子：
24
作者：
Rozanski,A;Diamond,GA;Forrester,JS;Berman,DS;Morris,D;Jones,RH;Okada,R;Freeman,M;Swan,HJ
通讯作者：
Swan,HJ
跑步机上的无痛运动 ST 偏差：长期预后。
影响因子：
24
作者：
Mark,DB;Hlatky,MA;Califf,RM;MorrisJr,JJ;Sisson,SD;McCants,CB;Lee,KL;HarrellJr,FE;Pryor,DB
通讯作者：
Pryor,DB