心肺运动试验在微血管性心绞痛中的诊断及预测价值

The Diagnostic and Prognostic Value of Cardiopulmonary Exercise Testing in Microvascular Angina

摘要: 微血管性心绞痛(MVA)是临床上常见的非阻塞性冠状动脉缺血性心脏病，其诊断困难，往往为经验性诊治。传统的检查手段如冠脉造影或冠状动脉内注射腺苷和乙酰胆碱(Ach)有创诊断手段相比，可能面临着部分患者人群中存在局限性(如肾功能不全、甲状腺功能相关疾病、造影剂过敏等)而无法准确判断患者是否存在冠状动脉微血管功能障碍(CMD)引起的心肌缺血。而心肺运动试验(CPET)作为无创检查，可反映CMD中可能被改变的病理生理过程。然而，专门针对MVA患者队列的直接证据非常有限，现有数据大多来自阻塞性冠状动脉疾病、心力衰竭或混合胸痛人群的研究。CPET在MVA中“独立的预后价值”目前尚未在经混杂因素校正的多变量模型中得到验证。CPET在MVA的评估中具有理论前景，但现有证据不支持其具有明确诊断或独立预后价值的结论。迫切需要开展针对明确诊断的MVA患者的大规模前瞻性研究。

Abstract: Microvascular angina (MVA) is a clinically common form of non-obstructive coronary ischemic heart disease that is difficult to diagnose and is often managed empirically. Compared to traditional invasive diagnostic methods such as coronary angiography or intracoronary injection of adenosine and acetylcholine (Ach), these approaches may face limitations in certain patient populations (e.g., those with renal insufficiency, thyroid-related disorders, or contrast agent allergies), making it difficult to accurately determine whether myocardial ischemia is caused by coronary microvascular dysfunction (CMD). In contrast, cardiopulmonary exercise testing (CPET), as a noninvasive test, can reflect the pathophysiological processes that may be altered in CMD. However, direct evidence specifically targeting the MVA patient cohort is very limited; most existing data come from studies of patients with obstructive coronary artery disease, heart failure, or mixed chest pain. The “independent prognostic value” of CPET in MVA has not yet been validated in multivariate models adjusted for confounding factors. While CPET holds theoretical promise for the evaluation of MVA, current evidence does not support the conclusion that it has definitive diagnostic or independent prognostic value. There is an urgent need for large-scale prospective studies involving patients with a confirmed diagnosis of MVA.