JAMA：ECG异常的老年人冠心病事件发作的风险可能增加

4月11日，国际杂志《美国医学会杂志》JAMA上的一项研究披露，在一项包括没有预先存在的心血管疾病的老年男女的研究中，严重的及轻微的心电图异常与冠心病（CHD）事件风险的增加有关，且它们能够超越传统的心血管风险因子而改善对诸如心脏病发作等CHD事件的预测。

根据文章的背景资料：“在老年人群中，通过传统的风险因子来预测CHD没有其在中年人中的预测那样精确。”心电图（ECG）异常在老年人中是常见的。 “然而，目前的证据不支持在无症状的成年人中做常规的ECG。考虑到老年人中心血管疾病（CVD）和ECG异常皆有较高的发生率，因此在该组病人中结合ECG的风险预测可能更加有用。迄今为止，很少有研究检验在老年人群中用ECG异常来改善CVD的风险预测，且没有研究能够充分地校正对先前存在的CVD及传统的心血管风险因子（CVRFs）的分析。”

瑞士洛桑大学及加州大学旧金山分校的Reto Auer， M.D.及其同事们开展了一项研究，旨在确定基线（即在研究开始时的）状态的严重的及轻微的ECG异常、新的ECG异常的发生及在随访期间持续性的ECG异常是否与新的CHD事件有关系，而且其关系是不依赖于传统的心血管风险因子的。该基于人群的研究中包括了2，192名老年的白人和黑人，其年龄在70-79岁，他们没有已知的心血管疾病。判定的CHD事件是在1997-1998及2006-2007这8年中汇集的。基线状态及4年ECG异常被分类为严重和轻微的异常。研究人员对ECG异常加上传统的风险因子以预测CHD事件进行了检验。

在该研究的2，192名参与者中，有506人（23%）有严重的ECG异常，有276人（13%）有轻微的ECG异常。在中位数（中点）为8.2年的随访期间，351名参与者发生了CHD事件[有96例CHD死亡，101例急性心肌梗塞（MIs；心脏病发作）及154例因为心绞痛或冠状动脉血运重建而住院]及602人死亡（96人死于CHD）。数据分析表明，基线状态时的严重和轻微的ECG异常都与CHD风险增加有关。在经过对各种心血管风险因子——包括年龄、性别、总体及高密度脂蛋白胆固醇、收缩压、吸烟和糖尿病——进行校正之后，与没有ECG异常的参与者相比，在基线情况下有轻微ECG异常者发生CHD事件的风险增加了35%，而在基线情况下有严重ECG异常者发生CHD的风险增加了51%。按种族所进行的分层分析显示，在白人和黑人参与者中的发现是类似的。

研究人员写道：“总之，我们发现ECG的严重及轻微的异常与未来的CHD事件有关，它们超越了传统的风险因子而给人们提供了适度改善的风险再分类。在老年人中，用传统的风险因子进行风险预测没有其在中年人中那样精确。鉴于ECG的安全性、低成本及广泛的可获得性，ECG数据可能对改善老年人的CHD风险预测有用。ECG是否应该被纳入到对老年人的常规筛检之中应该由随机对照的试验来评估。”

doi:10.1001/jama.2012.434
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Association of Major and Minor ECG Abnormalities With Coronary Heart Disease Events

Reto Auer, MD; Douglas C. Bauer, MD; Pedro Marques-Vidal, MD, PhD; Javed Butler, MD, MPH; Lauren J. Min, PhD; Jacques Cornuz, MD, MPH; Suzanne Satterfield, MD; Anne B. Newman, MD, MPH; Eric Vittinghoff, PhD; Nicolas Rodondi, MD, MAS for the Health ABC Study

Context In populations of older adults, prediction of coronary heart disease (CHD) events through traditional risk factors is less accurate than in middle-aged adults. Electrocardiographic (ECG) abnormalities are common in older adults and might be of value for CHD prediction. Objective To determine whether baseline ECG abnormalities or development of new and persistent ECG abnormalities are associated with increased CHD events. Design, Setting, and Participants A population-based study of 2192 white and black older adults aged 70 to 79 years from the Health, Aging, and Body Composition Study (Health ABC Study) without known cardiovascular disease. Adjudicated CHD events were collected over 8 years between 1997-1998 and 2006-2007. Baseline and 4-year ECG abnormalities were classified according to the Minnesota Code as major and minor. Using Cox proportional hazards regression models, the addition of ECG abnormalities to traditional risk factors were examined to predict CHD events. Main Outcome Measure Adjudicated CHD events (acute myocardial infarction [MI], CHD death, and hospitalization for angina or coronary revascularization). Results At baseline, 276 participants (13%) had minor and 506 (23%) had major ECG abnormalities. During follow-up, 351 participants had CHD events (96 CHD deaths, 101 acute MIs, and 154 hospitalizations for angina or coronary revascularizations). Both baseline minor and major ECG abnormalities were associated with an increased risk of CHD after adjustment for traditional risk factors (17.2 per 1000 person-years among those with no abnormalities; 29.3 per 1000 person-years; hazard ratio [HR], 1.35; 95% CI, 1.02-1.81; for minor abnormalities; and 31.6 per 1000 person-years; HR, 1.51; 95% CI, 1.20-1.90; for major abnormalities). When ECG abnormalities were added to a model containing traditional risk factors alone, 13.6% of intermediate-risk participants with both major and minor ECG abnormalities were correctly reclassified (overall net reclassification improvement [NRI], 7.4%; 95% CI, 3.1%-19.0%; integrated discrimination improvement, 0.99%; 95% CI, 0.32%-2.15%). After 4 years, 208 participants had new and 416 had persistent abnormalities. Both new and persistent ECG abnormalities were associated with an increased risk of subsequent CHD events (HR, 2.01; 95% CI, 1.33-3.02; and HR, 1.66; 95% CI, 1.18-2.34; respectively). When added to the Framingham Risk Score, the NRI was not significant (5.7%; 95% CI, −0.4% to 11.8%). Conclusions Major and minor ECG abnormalities among older adults were associated with an increased risk of CHD events. Depending on the model, adding ECG abnormalities was associated with improved risk prediction beyond traditional risk factors.