心肺运动试验摄氧量恢复延迟对经皮冠状动脉介入治疗术后患者预后的影响

目的探讨心肺运动试验(CPET)摄氧量恢复延迟(VO₂RD)对经皮冠状动脉介入治疗(PCI)术后心电图运动试验阴性患者预后的影响。方法回顾性分析北京大学第三医院2018年1月至2019年9月在PCI术后半年内行CPET且心电图运动试验阴性患者1268例,收集患者的临床资料、冠状动脉造影及介入操作资料、实验室检查、超声心动图及CPET检查结果。所有患者通过门诊或电话随访,记录患者不良心血管事件,包括死亡、心肌梗死、卒中、短暂性脑缺血发作、非计划再次PCI、周围血管介入治疗、不稳定型心绞痛和急性心力衰竭事件引起的住院。采用多因素Cox回归分析探讨CPET VO₂RD是否影响PCI术后心电图运动试验阴性患者的预后。结果1268例入选患者中完成随访1218例,失访50例,随访14(10,20)个月,共发生不良心血管事件105例(8.6%)。不良事件组年龄[(62.4±9.9)岁比(60.3±10.2)岁,P=0.020]、不完全血运重建比例(42.9%比31.6%,P=0.022)以及合并高脂血症比例(79.0%比68.0%,P=0.020)均显著高于无不良事件组;糖化血红蛋白值[(7.3±1.1)%比(6.6±1.2)%,P=0.001]、空腹血糖[(7.1±2.6)mmol/L比(6.5±1.9)mmol/L,P=0.010]及N末端B型脑钠肽前体[107.5(50.1,399.8)pg/ml比88.2(39.2,225.0)pg/ml,P=0.017]显著高于无不良事件组;峰值心率[(121±18)次/分比(126±20)次/分,P=0.012]、无氧阈心率[(99±12)次/分比(102±14)次/分,P=0.029]和峰值摄氧量[(17.3±4.7)ml/(min·kg)比(18.7±2.1)ml/(min·kg),P=0.003]显著低于无不良事件组,二氧化碳通气当量斜率[(33.3±9.2)比(28.1±5.1),P=0.001]和VO₂RD[(21.4±4.5)s比(18.5±5.4)s,P=0.001]显著高于无不良事件组。多因素Cox回归分析显示VO₂RD>20 s(HR 1.594,95%CI 1.026~2.476,P=0.038)是PCI术后心电图运动试验阴性患者发生不良心血管事件的独立危险因素。结论PCI术后心电图运动试验阴性的患者仍有一定的不良心血管事件发生风险,CPET恢复期指标VO₂RD>20 s是此类患者发生不良心血管事件的独立预测因素。

Impact of delayed recovery of oxygen uptake in cardiopulmonary exercise test on the prognosis after percutaneous coronary intervention

Objective To evaluate the impact of oxygen uptake recovery delay(VO₂RD) in patients with negative electrocardiogram(ECG)exercise test in cardiopulmonary exercise testing(CPET)after percutaneous coronary intervention(PCI).Methods We retrospectively analyzed the clinical data from 1268 patients who received PCI treatment and had negative ECG exercise test in CPET within half a year after PCI in Peking University Third Hospital from January 2018 to September 2019.The clinical features,coronary angiography and interventional operation data,laboratory examination,echocardiogram and CPET were analyzed.All patients were followed up by outpatient or telephone call to record adverse cardiovascular events,including death,myocardial infarction,stroke,transient ischemic attack,unplanned PCI,peripheral vascular intervention,hospitalization caused by unstable angina pectoris and acute heart failure events.Multivariate Cox regression analysis was used to explore whether the VO₂ RD in CPET affected the prognosis of patients with negative ECG exercise test after PCI.Results Among the 1268 enrolled patients,a total of 1218 patients finished follow up while 50 cases were lost.The median follow-up was 14(10,20)months.A total of 105 cases(8.6%)had adverse cardiovascular events.Compared with the non-adverse event group,the patients in the adverse events group were older[(62.4±9.9)years vs.(60.3±10.2)years,P=0.020],with higher proportion of incomplete revascularization(42.9%vs.31.6%,P=0.022)and hyperlipidemia(79.0%vs.68.0%,P=0.020),glycosylated hemoglobin[(7.3±1.1)%vs.(6.6±1.2)%,P=0.001],fasting blood glucose[(7.1±2.6)mmol/L vs.(6.5±1.9)mmol/L,P=0.010]and N-terminal natriuretic peptide precursor[107.5(50.1,399.8)pg/ml vs.88.2(39.2,225.0)pg/ml,P=0.017];while with lower peak heart rate[(121±18)bpm vs.(126±20)BPM,P=0.012],a naerobic threshold heart rate[(99±12)bpm vs.(102±14)bpm,P=0.029]and peak oxygen uptake[(17.3±4.7)ml/(min·kg)vs.(18.7±2.1)ml/(min·kg),P=0.003];and with higher carbon dioxide ventilation equivalent slope[(33.3±9.2)vs.(28.1±5.1),P=0.001]and VO₂RD[(21.4±4.5)s vs.(18.5±5.4)s,P=0.001].Multivariate Cox regression analysis showed that VO₂RD>20 s(HR1.594,95%CI 1.026-2.476,P=0.038)was an independent risk factor for adverse cardiovascular events in patients with negative ECG exercise test in CPET after PCI.Conclusions Patients with negative electrocardiogram in CPET after PCI still have a certain risk of adverse cardiovascular events.VO₂RD>20 s is an independent predictor of adverse cardiovascular events in such patients.