■生理缺血与解剖严重程度对稳定性冠状动脉疾病(CAD)患者的预后和管理的价值存在广泛争议。
■共有1764名接受休息应激镉-锌-碲单光子发射计算机断层扫描心肌灌注成像和血管造影(侵入性或计算机断层扫描)的患者被前瞻性纳入并随访心脏死亡/非致死性心肌梗死。CAD预后指数(CADPI)用于量化血管造影疾病的范围和严重程度。使用Cox模型评估预后价值,根据预测试风险进行调整,已知的CAD,压力源,左心室射血分数,%缺血和梗塞,CADPI,和早期(90天)血运重建。使用净重新分类指数评估增量预后价值。
■平均年龄为69.7±9.5岁,24.4%是女性,29.3%的人知道CAD。28.4%存在显著缺血(>10%)。非阻塞性,单身,多支血管疾病有256例(14.5%),772(43.8%),和736(41.7%),分别。579例发生早期血运重建(32.8%)。在4.6年的中位随访中,148例(8.4%)发生了心脏死亡/心肌梗死。%缺血和CADPI均提供了独立和递增的预后价值,超过了测试前的临床风险(P<0.001)。在包含缺血和解剖结构的模型中,缺血是预后性的(每5%的风险比,1.35[95%CI,1.11-1.63];P=0.002),但CADPI不是(每10个单位的危险比,1.09[95%CI,0.99-1.20];P=0.07)。早期血运重建改变了与%缺血相关的风险(交互作用P=0.003),但与CADPI无关(交互作用P=0.6)。%缺血和单光子发射计算机断层扫描变量增加了临床风险和CADPI(净重新分类指数,20.3%[95%CI,9%-32%];P<0.05);然而,CADPI没有超出测试前风险的增量预后,%缺血,和单光子发射计算机断层扫描变量(净重新分类指数,3.1%[95%CI,-5%至15%];P=0.21)。
■缺血负荷提供了超越CAD解剖结构的独立和递增的预后价值,并确定了从早期血运重建中获益的患者。与临床危险因素相比,疾病的解剖范围具有独立的预后价值,但对预后和指导超出生理严重程度(缺血)的血运重建的益处有限。
UNASSIGNED: The value of physiological ischemia versus anatomic severity of disease for prognosis and management of patients with stable coronary artery disease (CAD) is widely debated.
UNASSIGNED: A total of 1764 patients who had rest-stress cadmium-zinc-telluride single-photon emission computed tomography myocardial perfusion imaging and angiography (invasive or computed tomography) were prospectively enrolled and followed for cardiac death/nonfatal myocardial infarction. The CAD prognostic index (CADPI) was used to quantify the extent and severity of angiographic disease. Prognostic value was assessed using Cox models, adjusted for pretest risk, known CAD, stressor, left ventricular ejection fraction, %ischemia and infarct, CADPI, and early (90-day) revascularization. Incremental prognostic value was evaluated using net reclassification index.
UNASSIGNED: The mean age was 69.7±9.5 years, 24.4% were women, and 29.3% had known CAD. Significant ischemia (>10%) was present in 28.4%. Nonobstructive, single, and multivessel disease was present in 256 (14.5%), 772 (43.8%), and 736 (41.7%), respectively. Early revascularization occurred in 579 (32.8%). Cardiac death/myocardial infarction occurred in 148 (8.4%) over a 4.6-year median follow-up. Both %ischemia and CADPI provided independent and incremental prognostic value over pretest clinical risk (P<0.001). In a model containing both ischemia and anatomy, ischemia was prognostic (hazard ratio per 5% ↑, 1.35 [95% CI, 1.11-1.63]; P=0.002) but CADPI was not (hazard ratio per 10-unit ↑, 1.09 [95% CI, 0.99-1.20]; P=0.07). Early revascularization modified the risk associated with %ischemia (interaction P=0.003) but not with CADPI (interaction P=0.6). %Ischemia and single-photon emission computed tomography variables added incremental prognostic value over clinical risk and CADPI (net reclassification index, 20.3% [95% CI, 9%-32%]; P<0.05); however, CADPI was not incrementally prognostic beyond pretest risk, %ischemia, and single-photon emission computed tomography variables (net reclassification index, 3.1% [95% CI, -5% to 15%]; P=0.21).
UNASSIGNED: Ischemic burden provides independent and incremental prognostic value beyond CAD anatomy and identifies patients who benefit from early revascularization. The anatomic extent of disease has independent prognostic value over clinical risk factors but offers limited incremental benefit for prognosis and guiding revascularization beyond physiological severity (ischemia).