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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_4048_Библиотеки_им_академика_М_И_Перельмана
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181
the control group. In group 1, in 203 patients (99%; 95% CI 97-100%), the stress
test was recognized as ischemic, in group 2 – in 65 patients (94%; 95% CI
87-98%), in the control group – in 12 people (35%; 95% CI 20-52%), p<0.00001.
The average stress in group 1 was 70±29 W, in group 2 – 76±35 W, in the control
group – 127±43 W, p<0.0000001. The achieved heart rate during exercise in group
1 was on average 106±17 beats per minute, in group 2 – 110±21 beats per minute,
in the control group – 132±20 beats per minute, p<0.0000001. The maximum
arterial pressure during exercise in group 1 was on average 170±25 mmHg, in
group 2 – 173±26 mm Hg, in the control group – 187±26 mmHg, p<0.002.
/
5.4.4. Results of coronary angiography
Coronary angiography was made in 176 patients in group 1, 62 patients in group 2
and 7 persons from the control group. In 160 (91%) patients of group 1,
independent X-ray endovascular specialists diagnosed >50% stenoses in the left
main artery, pLAD/pLCx. In group 2, 42 (69%) had angiographic signs of >50%
stenosis in mLAD/mLCx. In the control group, 1 patient (14%) had a lesion of the
right coronary artery of more than 50%, the remaining 6 persons in the control
group were not diagnosed with significant stenoses according to coronary
angiography, p<0.000001.
5.4.5. Clinical outcomes of patients during the year.
During the observation period, contact with 4 patients was lost, all patients from
group 1 remained, the final group consisted of 357 people (99% of the initial).
5.4.5.1. Overall mortality analysis
The average follow-up period was 10.5 months. Fatal outcomes were observed in
17 cases. Cardiovascular death was proven in 13 cases, it was not possible to find
out the cause of death in 3 cases, in one case the cause of death was cancer.
Death occurred in group 1 only (6.4% vs. 0% vs. 0%, p<0.009, in group 1 vs.
group 2 vs. control group, respectively). Kaplan-Meier curves Fig. 5.8
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Fig. 5.8. Kaplan-Meier survival curves of patients in Group 1, Group 2, control
group.
Comparative characteristics of deceased and surviving patients are given in Table
5.2.
Table 5.2. Comparative characteristics of deceased and surviving patients.
Surviving
patients
N=391
Deceased
patients
N=17
P value
Age (years)
61±11
72±13
P<0.0002
Sex (M/F)
256/135
10/7
NS
BMI (kg/m2)
28.7±5
25.7±5
Р<0.003
Hypertension
325 (83%)
13 (77%)
NS
Previous CAD
176 (45%)
6 (35%)
NS
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183
Previous PCI
91 (23.2%)
0 (0%)
Р<0.002
Diabetes mellitus
59 (15,1%)
2 (11,8%)
NS
Previous MI
123 (31,4%)
3 (17,7%)
NS
Echocardiography
EF, %
61,5±10
57,9±19
NS
EDV, ml
108,4±36
115,4±37
NS
Exercise test
Maximal HR
(beats/min)
110±20
105±16
NS
Exercise capacity
(W)
77,7±37
56,2±13
NS
Maximal blood
pressure, mmHg
173±26
150±27
NS
Coronary artery velocity at rest
Max velocity in
LM/proximal
LAD/proximal LCx
87,6±36
132±50
Р<0.000002
Max velocity in
middle LAD/middle
LCx
78±40
113±52
NS
LM – left main artery; pLAD – proximal portion of left anterior descending artery; pLCx –
proximal portion of left circumflex artery; mLAD – middle portion of left anterior descending
artery; mLCx – middle portion of left circumflex artery.
Multivariate and ROC Analysis
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The age limit value for predicting death was over 72 years. Sensitivity was 59%,
specificity – 84%, accuracy – 73%, p<0.0009. Fig. 5.9.
Fig 5.9 Accuracy of predicting death by age of patients
The limit value BMI for predicting death was less than 24.4 kg /m2. Sensitivity
was 54%, specificity – 85%, accuracy – 69%, p<0.04. Figure 5.10.
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185
Fig 5.10 Limit value of body mass index for predicting death
The limit value blood flow velocity in the proximal portions of the left coronary
artery for predicting death was more than 109 cm/s. Sensitivity was 65%,
specificity – 79%, accuracy – 76%, p<0.0001. Fig. 5.11.
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Fig. 5.11. The accuracy of predicting death by velocity in the proximal portions of
the left coronary artery
In multivariate analysis, only the maximum velocity in the proximal portions of the
arteries under study was an independent predictor of death from any cause (OR
1,02, 95% CI 1.01–1.03, P<0.02).
5.4.5.2. Analysis of the incidence of acute coronary events
Acute coronary events, which included: myocardial infarction, pulmonary edema,
unstable cardiac angina, were registered in 19 patients, which amounted to 4.7% of
the total number of patients in all groups. In group 1, there were 18 cases of acute
coronary events (6.76%), in the second group – 1 case (1.09%), in the control
group there were no acute coronary events p<0.004. Kaplan-Meier curves Fig.
5.12.
Fig. 5.12. Kaplan-Meier survival curves – the incidence of acute coronary events in
Group 1, Group 2 and control group.
Comparative characteristics of patients with acute coronary events are given in
Table 5.3.
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187
Table 5.3.
Without ACS
N=389
With ACS
N=19
P value
Age (years)
61±11
69±14
Р<0.004
Sex (M/F)
253/136
11/8
NS
BMI (kg/m2)
28,6±4,7
28,4±5,6
NS
Hypertension
324 (83,3%)
16 (84,2%)
NS
Previous CAD
175 (45%)
9 (47,3%)
NS
Previous PCI
88 (22,6%)
2 (10,5%)
NS
Diabetes mellitus
56 (14,4%)
3 (15,8%)
NS
Previous MI
118 (30,3%)
5 (26,3%)
NS
Echocardiography
EF, %
61,5±10
58,1±15
NS
EDV, ml
109±36
111±34
NS
Exercise test
Maximal HR (bpm)
110±20
105±14
NS
Exercise capacity
(W)
78±37
53±8
0.04
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Maximal blood
pressure, mmHg
173±26
166±27
NS
Coronary artery velocity at rest
Max velocity in
LM/pLAD/pLCx
88±36
128±50
Р<0.00003
Max velocity in
mLAD/mLCx
77±40
116±31
NS
LM – left main artery; pLAD – proximal portion of left anterior descending artery; pLCx –
proximal portion of left circumflex artery; mLAD – middle portion of left anterior descending
artery; mLCx – middle portion of left circumflex artery.
Multivariate and ROC Analysis
The age limit value for predicting acute coronary events was over 63 years.
Sensitivity was 74%, specificity – 56%, accuracy – 67%, p<0.002. Fig. 5.13.
Fig. 5.13. The accuracy of predicting acute coronary events by age.
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189
The exercise capacity limit value for stress echocardiography for predicting acute
coronary events was less than or equal to 50 W. Sensitivity was 89%, specificity –
53%, accuracy – 72%, p<0.0001. Fig. 5.14.
Fig. 5.14. Accuracy of predicting acute coronary events by the capacity of
endurable physical exercise
The limit value blood flow velocity in the proximal portions of the left coronary
artery for predicting acute coronary events was more than 88 cm/s. Sensitivity was
88%, specificity – 54%, accuracy – 75%, p<0.0001. Fig. 5.15.
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Fig. 5.15. The accuracy of predicting acute coronary events by velocity in the
proximal portions of the left coronary artery
In multivariate analysis, the maximum velocity in the proximal portions of the left
coronary artery (OR 1.01, 95% CI 1.00–1.03, P<0.02) and age (OR 1.01, 95% CI
1.06–1.11, P<0.03) were independent predictors of acute coronary events
5.4.5.3. Frequency analysis of cumulative point of deaths and acute coronary
events
The group of patients, among whose unfavorable outcomes were death, myocardial
infarction, pulmonary edema, unstable cardiac angina, consisted of 27 persons,
which is 6.6% of the total patients in all groups. In group 1, there were 26 cases of
deaths and acute coronary events (10%), in the second group – 1 case (1.11%), in
the control group there were no deaths and acute coronary events p<0.0002.
Kaplan-Meier curves Fig. 5.16.
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