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Implications of Abnormal Exercise Electrocardiography With Normal Stress Echocardiography
JAMA Internal Medicine ( IF 22.5 ) Pub Date : 2020-04-01 , DOI: 10.1001/jamainternmed.2019.6958
Melissa A Daubert 1, 2 , Joseph Sivak 3 , Allison Dunning 2 , Pamela S Douglas 1, 2 , Brian Coyne 1 , Tracy Y Wang 1, 2 , Daniel B Mark 1, 2 , Eric J Velazquez 4
Affiliation  

Importance Patients with abnormal (positive) exercise electrocardiography, but normal stress echocardiography (+ECG/-Echo) are commonly encountered in clinical practice; however, the prognostic significance of this discordant result is unclear. Objective To determine whether patients with +ECG/-Echo have a higher rate of adverse clinical events and a poorer prognosis than patients with negative exercise ECG and normal stress Echo imaging (-ECG/-Echo). Design, Setting, and Participants Between January 1, 2000, and February 28, 2014, a total of 47 944 consecutive patients without known coronary artery disease who underwent exercise stress Echo at Duke University Medical Center were evaluated for inclusion in this observational cohort study. Data analysis was conducted from January 1, 2000, to December 31, 2016. Interventions/Exposures Patients were categorized as having -ECG/-Echo, +ECG/-Echo, or +Echo (-ECG/+Echo and +ECG/+Echo). Main Outcomes and Measures The primary outcome was a composite end point of death, myocardial infarction, hospitalization for unstable angina, and coronary revascularization. Secondary outcomes included individual adverse events and downstream testing. Results After excluding submaximal tests and nondiagnostic ECG or stress imaging results, 15 077 patients (mean [SD] age, 52 [13] years; 6228 [41.3%] men) were classified by stress test results. Of these, 12 893 patients (85.5%) had -ECG/-Echo, 1286 patients (8.5%) had +ECG/-Echo, and 898 patients (6.0%) had +Echo. Through a median follow-up of 7.3 (interquartile range, 4.4-10.0) years, the composite end point occurred in 794 patients with -ECG/-Echo (8.5%), 142 patients with +ECG/-Echo (14.6%), and 297 patients with +Echo (37.4%). Death occurred in 425 patients with -ECG/-Echo (4.8%), 50 patients with +ECG/-Echo (5.9%), and 70 patients with +Echo (11.2%). Myocardial infarction occurred in 195 patients with -ECG/-Echo (2.2%), 31 patients with +ECG/-Echo (3.6%), and 59 patients with +Echo (8.7%). The addition of stress ECG findings to clinical and exercise data yielded incremental prognostic value. Patients with -ECG/-Echo imaging results had the least downstream testing (2.3%), followed by +ECG/-Echo (12.8%), and +Echo (33.6%) (P < .001). Conclusions and Relevance The presence of +ECG results with normal stress Echo imaging may identify a population of patients who are at slightly increased risk for adverse cardiac events, which was not previously recognized. Further study is needed to determine whether these patients will benefit from intensification of medical management.

中文翻译:

异常运动心电图对正常负荷超声心动图的影响

重要性 运动心电图异常(阳性)但负荷超声心动图正常(+ECG/-Echo)的患者在临床实践中很常见;然而,这种不一致结果的预后意义尚不清楚。目的 确定+ECG/-Echo 患者是否比运动心电图和正常应激回波成像(-ECG/-Echo)阴性患者有更高的临床不良事件发生率和更差的预后。设计、设置和参与者 在 2000 年 1 月 1 日至 2014 年 2 月 28 日期间,共有 47 944 名在杜克大学医学中心接受运动负荷 Echo 的无已知冠状动脉疾病的连续患者接受评估以纳入这项观察性队列研究。数据分析时间为2000年1月1日至2016年12月31日。干预/暴露 患者被分类为 -ECG/-Echo、+ECG/-Echo 或 +Echo(-ECG/+Echo 和 +ECG/+Echo)。主要结果和措施 主要结果是死亡、心肌梗死、不稳定心绞痛住院和冠状动脉血运重建的复合终点。次要结果包括个别不良事件和下游测试。结果 排除次极量试验和非诊断性心电图或压力成像结果后,15 077 名患者(平均 [SD] 年龄,52 [13] 岁;6228 [41.3%] 名男性)根据压力测试结果进行分类。其中,12 893 名患者(85.5%)有-ECG/-Echo,1286 名患者(8.5%)有+ECG/-Echo,898 名患者(6.0%)有+Echo。通过中位随访 7.3(四分位距,4.4-10.0)年,复合终点发生在 794 名 -ECG/-Echo 患者(8.5%)中,+ECG/-Echo 患者 142 名 (14.6%),+Echo 患者 297 名 (37.4%)。425 名 -ECG/-Echo 患者(4.8%)、50 名 +ECG/-Echo 患者(5.9%)和 70 名 +Echo 患者(11.2%)发生死亡。-ECG/-Echo 患者 195 例(2.2%),+ECG/-Echo 患者 31 例(3.6%),+Echo 患者 59 例(8.7%)发生心肌梗死。将压力心电图结果添加到临床和运动数据中产生了增加的预后价值。具有 -ECG/-Echo 成像结果的患者的下游检测最少 (2.3%),其次是 +ECG/-Echo (12.8%) 和 +Echo (33.6%) (P < .001)。结论和相关性 正常压力回波成像的 +ECG 结果的存在可能会识别出一组患者,这些患者发生不良心脏事件的风险略有增加,而这一点以前并未被认识到。
更新日期:2020-04-01
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