ASIST:阿替洛尔控制无症状性缺血的研究

作　　者　 (a)阿替洛尔控制无症状性缺血的研究(b)PepineCJ ,CohnPF ,DeedwaniaPC ,etal标　　题　 (a)阿替洛尔控制无症状缺血的研究这一检测和治疗无症状性缺血对预后和卫生经济学策略的影响 ;(b)探讨对日常生活中即有轻度症状的缺血患者进行治疗对预后的影响参考文献　 (a)ClinCardiol,1991,14 :4 5 7～ 4 6 2(b)Circulation ,1994 ,90 :76 2～ 76 8　　入选标准　无症状性缺血 ,冠心病。研究目的　评估缺血发作频率及发作时间对心脏事件发生率的影响。并分析阿替洛尔的治疗效应。试验设计　随机、双盲、安慰剂对照。随访时间　平…     

动态心电图对无症状性心肌缺血的诊断价值

对４６８例冠心病患者行动态心电图监测，发现１６２例无症状性心肌缺血患者，共出现心肌缺血发作４４３例阵次，大多数在６～１８时发作，与运动量大小有关，发作时快频率依赖者７９．６９％。     

动态心电图诊断无症状性心肌缺血的价值研究

目的：探讨动态心电图诊断无症状性心肌缺血的临床价值。方法：选取2012年10月～2014年8月在本院确诊为冠心病的患者90例,进行24小时动态心电图检测。结果：90例冠心病患者中检出心肌缺血75例(83.33％),48小时内发生缺血性ST段下移1075阵次。其中有症状性心肌缺血27例(36.00％),ST段下移155阵次(14.42％),平均ST段下移(0.17±0.03) mV;无症状性心肌缺血48例(64.00％),ST段下移920阵次(85.58％),平均ST段下移(0.16±0.02) mV。无症状性心肌缺血发作主要分布在6：00～18：00,其中6：00～12：00最多,白天发作时夜间发作的2.48倍。48例无症状性心肌缺血患者的平均心率为65/min,发作时心率＞65/min者36例(75.00％),≤65/min者12例(25.00％),伴有心律失常者41例(85.42％)。结论：动态心电图检测无症状性心肌缺血具有重要的临床诊断价值。     

无症状性心肌缺血并发心律失常相关因素研究

应用动态心电图（DCG）进行对无症状性心肌缺血（SMI）患者并发心律失常相关因素研究，设有SMI者为观察组，共216例，无SMI者为对照组，共136例。结果表明：SMI组心律失常检出率明显高于无SMI组:SMI组白天心律失常检出率明显高于夜间，与SMI发生呈一致；60岁以上SMI组男性患者恶性心律失常检出率最高；总SMI时间越长，发生恶性心律失常的频率越高。提示：及时掌握SMI并发心律失常情况及其规律，对于预防冠心病并发严重心律失常及猝死发生有重要意义。     

无症状性心肌严重缺血动态心电图1例

患者男性,46岁.既往体健.体检行24h动态心电图检查时,23:10～23:20(图1A)V1～V3ST段呈墓碑样抬高,Ⅱ、Ⅲ、aVF ST段下斜性压低0.15～0.30mV,T波呈负正双相.     

动态心电图对300例冠心病无症状性心肌缺血的分析

目的 探讨动态心电图(DCG)对冠心病无症状性心肌缺血(SMI)的诊断价值。方法 用CM3、CM2、MaVF监护导联作24h全信息记录,计算机回放、分析、记录、打印、人工判读,结合生活日志和临床分析诊断。结果 300例冠心病检出心肌缺血138例,其中SMI 103例(占74．2％)。结论 DCG是对冠心病SMI诊断最常用、最重要的方法之一,能动态反映SMI的程度、次数、时间以及与临床、日常生活的关系,提高对冠心病诊断的准确性,为制订治疗措施提供可靠依据。     

冠心病病人无症状性心肌缺血的临床分析

目的 探讨如何对无症状性心肌缺血（SMI）的冠心病病人进行早诊断及有效防治。方法 对126例冠心病病人进行24h动态心电图监测，据ST段压低情况及其同临床症状、发作时间、持续时间、心率变化及日常活动的关系做定性、定量分析。结果 126例中无症状性心肌缺血者79例，其中单纯性无症状性心肌缺血53例，无症状缺血型ST段压低发生次数是有症状的4.2倍。结论 并非每一位冠心病病人都有胸痛或与心肌缺血相关的主观症状，有一部分病人心电图表现为心肌缺血，但无胸痛或与心肌缺血相关的主观症状。     

动态心电图对无症状性心肌缺血的监测分析

目的探讨动态心电图对冠心病无症状性心肌缺血患者的临床诊断及其意义。方法对30例诊断明确的冠心病患者应用12导联24h动态心电图进行监测。结果 30例冠心病患者中,检测出心肌缺血者27例,其中无症状性心肌缺血ST改变占76%。结论动态心电图对无症状性心肌缺血的及时检出以及对治疗指导有较高的临床价值。     

动态心电图对无症状性心肌缺血的诊断价值

目的评价动态心电图在无症状性心肌缺血中的诊断价值及临床意义方法对60例确诊为冠心病的患者进行24h动态心电图检查,记录其ST段压低阵数及当时有无自觉症状和持续时间,并进行比较。结果有缺血型ST段改变者56例,占91%,其中有症状者18例,占30%,无症状者42例,占70%,ST段压低共160阵,有症状19阵,占31%,无症状者41阵,占69%。结论冠心病时无症状性心肌缺血十分常见。动态心电图提高了其检出率,对评估无症状性心肌缺血的预后有更重要的意义。     

动态心电图检测老年冠心病无症状性心肌缺血探讨

采用动态心电图对300例老年冠心病患者,在日常活动状态下,连续检测24小时。结果表明:有215例(占71.7％)发生无症状心肌缺血,发作次数592次(81.8％),与老年前期冠心病者比较都有非常显著性差异;80岁以上年龄组的无症状性心肌缺血检出率明显高于其他2个年龄组;运动时出现的无症状心肌缺血明显多于休息时;白天发作次数多于夜间。提示:掌握老年冠心病患者无症状心肌缺血发生规律,对老年冠心病的防治及预防严重并发症的发生有极大意义。     

Factors Influencing Clinical Outcomes After Revascularization in the Asymptomatic Cardiac Ischemia Pilot (ACIP)

Abstract Background and Aim The Asymptomatic Cardiac Ischemia Pilot is the first randomized trial where revascularization involved choice of either coronary bypass or angioplasty used in an early or a delayed symptom-driven approach. One-year outcomes were favorable (reduced recurrent ischemia and adverse outcomes) for an early revascularization strategy (within 4 weeks), compared with an early medical strategy when revascularization was delayed until symptom-driven. This ancillary study examined variables influencing outcomes after these 2 revascularization approaches (early vs. delayed until symptom-driven). Methods: Participants were clinically stable coronary disease patients with stress-induced and daily life ischemia who underwent revascvularization. Characteristics associated with clinical outcomes occurring within the year following revascularization were examined using Cox regression analysis. Results: A total of 262 patients received revascularization; 170 in the early approach and 92 in the delayed symptom-driven approach. Thirty-three patients had adverse outcomes (death, nonfatal myocardial infarction, or repeat revascularization) during l-year follow-up. The most important independent predictor of improved outcome during the follow-up year was attempted revascularization of ≥ 66% of vessels with significant stenosis for the early (risk ratio [RR] 0.25, 95% confidence interval [CI] 0.09–0.67) and the delayed (RR 0.21, CI 0.08–0.58) approaches. Factors such as age, stress test results, and coronary angiographic findings did not predict clinical outcome. Conclusions: Our findings are important in the planning of a large trial with longer follow-up.     

Cost estimates for treatment of cardiac ischemia (from the Asymptomatic Cardiac Ischemia Pilot [ACIP] study)

Costs for management of myocardial ischemia are enormous, yet comparison cost and outcome data for various ischemia treatment strategies from randomized trials are lacking and will require cost and resource utilization data from a large prospective trial. The Asymptomatic Cardiac Ischemia Pilot provided feasibility data for planning such a trial and an opportunity to estimate the long-term costs of different treatment strategies. Economic implications for ischemia management were compared in 558 patients with stable coronary artery disease and myocardial ischemia during both stress testing and daily life. Participants were randomized to 3 different initial treatment strategies and followed for 2 years. Based on cost trends over follow-up, costs for subsequent care were estimated. As expected, due to initial procedural costs, at 3 months, estimated costs for revascularization were approximately 10 times greater than costs for a medical care strategy. Extrapolated costs for anticipated resource consumption for care beyond 2 years, however, were approximately 2 times greater for an initial medical care strategy than for initial revascularization. This was due to increased need for drugs and hospitalizations for both late revascularizations and other ischemia-related events. Estimated costs for anticipated care in the medical strategies reached the anticipated cost of the revascularization strategy within 10 years. Because this cost-equal time period is well within the median life expectancy for such a patient population, these findings could have important public health implications and require testing in a full-scale prognosis trial. We anticipate that over the patients' life expectancy, early revascularization is likely to become either cost-neutral or cost-effective.     

The Asymptomatic Cardiac Ischemia Pilot (ACIP) study: Design of a randomized clinical trial,baseline data and implications for a long-term outcome trial

Objectives. The primary objectives of the Asymptomatic Cardiac Ischemia Pilot were 1) to compare the 12-week efficacy of three treatment strategies to suppress cardiac ischemia, and 2) to assess the feasibility of a prognosis trial in patients with asymptomatic cardiac ischemia.Background. Cardiac ischemia has been associated with increased morbidity and mortality. However, most cardiac ischemia is asymptomatic, and although therapeutic strategies ranging from no medication to revascularization are being used to treat ischemia, no prospective study evaluating different treatment strategies has been reported.Methods. Patients with angiographically documented coronary artery disease and ischemia on exercise and ambulatory electrocardiogram (ECG) in 11 clinical units were randomized to receive angina-guided medical therapy, angina-guided plus ambulatory ECG ischemia-guided medical therapy or revascularization (coronary angioplasty or bypass surgery). Patients were also randomized to receive either diltiazem plus isosorbide dinitrate or atenolol plus nifedipine when possible. After anti-ischemic medication adjustment to control angina, blinded medication was adjusted in the medical therapy groups to eliminate ischemia in the ischemia-guided group. The primary outcome was the absence of ischemia at 12 weeks. Follow-up was scheduled for 1 year.Results. A total of 1,959 patients were screened by ambulatory ECG monitoring; 982 (49%) had asymptomatic ischemia, and 618 (65%) were enrolled in the study. Most patients were men, were >60 years old and had two or more ischemic episodes, early positive exercise tests and multivessel disease.Conclusions. Design and baseline data for a pilot study of ischemia treatment strategies are described.     

Effects of treatment strategies to suppress ischemia in patients with coronary artery disease: 12-Week results of the Asymptomatic Cardiac Ischemia Pilot (ACIP) study

Objectives. The Asymptomatic Cardiac Ischemia Pilot (ACIP) study was initiated to determine the feasibility of a large trial in evaluating the effects of treatment of ischemia on outcome (mortality and myocardial infarction). The study was designed to examine the effects of medical treatment to control angina compared with treatment strategies guided by ambulatory electrocardiographic (ECG) ischemia or coronary anatomy.Background. Treatments to suppress ischemia (asymptomatic and symptomatic) have not been evaluated in a large prospective, randomized trial. Before undertaking such a trial, issues about recruitment and treatment strategies must be addressed.Methods. The 618 enrolled patients had coronary artery disease suitable for revascularization, ischemia on stress test and asymptomatic ischemia on ambulatory ECG. Patients were assigned randomly to one of three treatment strategies: 1) angina-guided medical strategy with titration of anti-ischemic medication to relieve angina (angina-guided strategy); 2) angina-guided plus ambulatory ECG ischemia-guided medical strategy with titration of anti-ischemic medication to eliminate both angina and ambulatory ECG ischemia (ischemia-guided strategy); and 3) revascularization by angioplasty or bypass surgery (revascularization strategy).Results. Ambulatory ECG ischemia was no longer present at the week 12 visit in 39% of patients assigned to the angina-guided strategy, 41% of patients assigned to the ischemia-guided strategy and 55% of patients assigned to the revascularization strategy. All strategies reduced the median number of episodes and total duration of ST segment depression during follow-up ambulatory ECG monitoring. Revascularization was the most effective strategy. Treadmill test results were concordant with those of ambulatory ECG monitoring, lor most patients in the two medical strategies, angina was controlled with low to moderate doses of anti-ischemic medication, and the majority of patients (65%) in the revascularization strategy did not require medication for angina.Conclusions. This pilot study demonstrated that cardiac ischemia can be suppressed in 40% to 55% of patients with either low or moderate doses of medication or revascularization and that a large trial is feasible.     

Relation Between Clinical, Angiographic and Ischemic Findings at Baseline and Ischemia-Related Adverse Outcomes at 1 Year in the Asymptomatic Cardiac Ischemia Pilot Study

Objectives. We attempted to investigate the relation between patient characteristics and adverse outcome in patients with ischemia and clinically stable coronary artery disease (CAD).

Background. Evidence suggests that cardiac ischemia, detected by exercise stress testing (ETT) and ambulatory electrocardiographic (AECG) monitoring during daily living, identifies a subgroup of patients at increased risk for adverse outcome, but the relation between these ischemia findings and clinical and angiographic characteristics is largely unknown.

Methods. We examined the relation between clinical, angiographic and ischemia characteristics at entry with adverse outcome observed at 1 year in the 558 patients enrolled in the Asymptomatic Cardiac Ischemia Pilot (ACIP) study.

Results. By the 12-month visit 13.1% of patients had an ischemia-related adverse clinical outcome that included death, nonfatal myocardial infarction or an ischemia-related hospital admission. Multivariate analysis identified only the number of AECG ischemic episodes at entry (odds ratio [OR] 1.06, 99% confidence interval [CI] 1.01 to 1.12, p = 0.002) as an independent predictor of outcome. Assignment to revascularization (as opposed to an initial medical treatment strategy) showed a trend (OR 0.56, 99% CI 0.26 to 1.2, p = 0.05). None of the other baseline clinical, exercise or angiographic variables examined provided additional information relative to adverse outcome.

Conclusions. Determinants of adverse outcome, among clinically stable patients with CAD and ischemia induced by stress and daily life were magnitude of AECG ischemia before treatment and, possibly, initial treatment assignment. Among the many other characteristics examined, including age, symptom status and angiographic and exercise variables, none contributed additional independent prognostic information. These two simple variables, which may be modifiable, need further study in a larger trial.

(J Am Coll Cardiol 1997;29:1483–9)     

Cardiac MRI For Myocardial Ischemia

Proper assessment of the physiologic impact of coronary artery stenosis on the LV myocardium can affect patient prognosis and treatment decisions. Cardiac magnetic resonance imaging (CMR) assesses myocardial perfusion by imaging the myocardium during a first-pass transit of an intravenous gadolinium bolus, with spatial and temporal resolution substantially higher than nuclear myocardial perfusion imaging. Coupled with late gadolinium enhancement (LGE) imaging for infarction during the same imaging session, CMR with vasodilating stress perfusion imaging can qualitatively and quantitatively assess the myocardial extent of hypoperfusion from coronary stenosis independent of infarcted myocardium. This approach has been validated experimentally, and multiple clinical trials have established its diagnostic robustness when compared to stress single-photon emission computed tomography. In specialized centers, dobutamine stress CMR has been shown to have incremental diagnostic value above stress echocardiography due to its high imaging quality and ability to image the heart with no restriction of imaging window. This paper reviews the technical aspects, diagnostic utility, prognostic values, challenges to clinical adaptation, and future developments of stress CMR imaging.     

无症状性颈动脉粥样硬化研究

标　　题　 1.无症状性动脉粥样硬化的颈动脉内膜切除术的随机前瞻性试验研究设计2 .无症状性颈动脉狭窄的动脉内膜切除术作　　者　 1.ＡＣＡＳ组　　 2 .ＡＣＡＳ执行委员会　　参考文献　 1.Ｓｔｒｏｋｅ ,1989,2 0 :84 4～ 84 9;2 .ＪＡＭＡ ,1995 ,2 73:14 2 1～ 14 2 8　　研究疾病　无症状性颈动脉狭窄(血流动力学显著改变 )。目　　的　探讨在无症状性颈动脉狭窄病人中 ,除积极药物治疗外 ,增加颈动脉内膜切除术能否减少脑梗死的发生率。设　　计　随机、开放、对照组。病人资料　 16 6 2例 ,年龄 4 0～ 79岁 ,至少 6 0 %的颈总动脉…     

无症状性与有症状心肌缺血的临床特征比较

对50例确诊为冠心病的病人进行了24小时动态心电监测。结果表明,无症状性心肌缺血次数明显多于有症状性心肌缺血次数(P<0.01);无症状性心肌缺血的病人明显多于有症状性心肌缺血的病人(P<0.01);有症状与无症状性缺血时的平均心率均明显快于缺血前的平均心率(P<0.01);6～12时及18～24时期间心肌缺血次数明显多于0～6时期间心肌缺血次数(P<0.05);有症状性与无症状性心肌缺血之间在平均缺血持续时间ST段下降幅度、缺血前及缺血时平均心率等方面无明显差异。