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#106
14.03.2007, 17:57
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!)Conclusions. After nitrate administration, tetrofosmin uptake in dysfunctional segments correlated with metabolic activity as assessed by fluorodeoxyglucose PET imaging better than baseline. Thus tetrofosmin SPECT after nitrate administration may improve the identification of ischemic but still viable myocardium in patients with chronic ischemic LV dysfunction.
36 patents 2) Conclusion: After nitrate administration, 99mTc-tetrofosmin uptake and perfusion defect severity were closely related to ceMRI, demonstrating, in vivo, the existence of an inverse correlation between the transmural distribution of fibrosis and tracer delivery to the myocardium. 19 patients [Ссылки доступны только зарегистрированным пользователям ] [Ссылки доступны только зарегистрированным пользователям ] [Ссылки доступны только зарегистрированным пользователям ] - Nothing new.  
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#107
14.03.2007, 18:09
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J Nucl Cardiol. 2003 Nov-Dec;10(6):696-9. Links
Comment on: J Nucl Cardiol. 2003 Nov-Dec;10(6):599-606. The quest for myocardial viability: Is there a role for nitrate-enhanced imaging? Di Carli MF. PMID: 14668784 [PubMed - indexed for MEDLINE] Left ventricular (LV) function is a well-established and powerful predictor of outcome after myocardial infarction (MI).1 Indeed, the occurrence of severe LV systolic dysfunction (ie, LV ejection fraction <30%) after MI, especially when combined with heart failure, is associated with very poor survival if treated with medical therapy alone.2 In selected patients high-risk surgical revascularization appears to afford a long-term survival benefit.3, 4 However, selection of patients with severe LV dysfunction for high-risk revascularization remains controversial. In some patients with coronary artery disease (CAD), LV dysfunction results from MI with attendant necrosis and scar formation. However, it is now clear that in many patients such myocardial dysfunction may be reversible with revascularization5; this is otherwise referred to as hibernating6 and/or stunned7 myocardium. Consequently, the distinction of LV dysfunction caused by fibrosis from that arising from viable but dysfunctional myocardium is a relevant diagnostic issue and has important implications for patients with low ejection fraction, in whom severe heart failure may be attributed to severe, widespread hibernation (or stunning or both) rather than to necrosis of a critical mass of myocardium.8 Failure to identify patients with these potentially reversible causes of heart failure may lead to progressive cellular damage, heart failure, and death. Competing methods for myocardial viability assessment Several noninvasive approaches have been proposed to identify myocardial viability and predict functional recovery in patients with LV dysfunction.5 These include the assessment of regional myocardial perfusion and/or metabolism, the delineation of cell membrane integrity, the measurement of myocardial contractile reserve, and more recently, the estimation of the amount of myocardial scar.9 When properly applied, all of these methods have been shown to be clinically useful for diagnosing viable myocardium.10 Of all scintigraphic methods, the single photon emission computed tomography (SPECT) approaches with thallium 201 and technetium 99m–labeled imaging agents are probably the most widely used in clinical practice. The unique kinetics of Tl-201 in myocardial tissue makes it an attractive and useful marker of cell viability, and in many laboratories it remains the cornerstone of viability assessment with SPECT. However, its relatively poor imaging characteristics (ie, low energy window, increased scatter, more attenuation artifacts, limited spatial resolution) represent an important practical limitation that often leads to diagnostic uncertainty. Because of the improved imaging properties of Tc-99m (ie, higher energy window, reduced scatter, less attenuation artifacts, improved spatial resolution), Tc-99m–labeled imaging agents are being used increasingly in the evaluation of tissue viability with SPECT. Like Tl-201, the uptake and retention of these agents require intact cell membrane properties. In situations in which rest myocardial blood flow is moderately or severely reduced, however, Tc-99m–labeled agents have inherent disadvantages compared with Tl-201 because of the lack of redistribution.11 Indeed, the myocardial uptake and retention of Tc-99m–labeled agents (reflecting viable myocardium) appear to be very similar to those of Tl-201 across a relatively wide range of perfusion deficits, except in severe perfusion defects, where they tend to underestimate the degree of viability.12 To overcome this limitation, several investigators have proposed the use of nitrate enhancement to improve tissue perfusion to areas of dysfunctional but viable myocardium in order to augment the availability and likelihood of retention of Tc-99m–labeled agents.13, 14, 15, 16, 17, 18 There is growing and consistent evidence demonstrating that in patients with regional and/or mild to moderate LV dysfunction, the improved uptake of Tc-99m–labeled agents after nitrovasodilators correlates well with indexes of preserved viability by Tl-201 SPECT13 and predicts functional recovery after revascularization.15, 16, 17, 18 Importance of the current study The article by He et al19 in this issue of the Journal provides further evidence regarding the added value of nitrate-enhanced imaging for diagnosing myocardial viability. In this study they evaluated the diagnostic equivalence between Tc-99m– tetrofosmin SPECT and fluorine 18–fluorodeoxyglucose (FDG) positron emission tomography (PET) in 36 patients with prior MI, 1- or 2-vessel CAD, and mild to moderate LV dysfunction. As expected, regional LV function at baseline correlated with the magnitude of tetrofosmin uptake. That is, myocardial segments showing akinesis or dyskinesis had a significantly lower tetrofosmin uptake than those showing hypokinesis or normal regional function. Before nitrate administration, tetrofosmin uptake (≥55% of peak) demonstrated residual viability in 78 of 131 akinetic or dyskinetic segments (60%), which was comparable to the number of segments identified as viable by FDG PET. After nitrate administration, 14 of the 53 segments (26%) considered nonviable at baseline tetrofosmin imaging showed an increase in tracer uptake (≥10% from baseline) and, thus, were reclassified as viable. On a per-patient basis, nitrate-enhanced tetrofosmin imaging reclassified 4 of 9 patients (44%) demonstrating no viability at baseline imaging as having clinically significant residual viability. However, 20 of the 39 segments (51%) or 1 of 5 patients showing no improvement in tracer uptake after nitrate administration, and thus considered nonviable by tetrofosmin SPECT, had evidence of residual viability by FDG PET. Overall concordance between tetrofosmin SPECT and FDG PET improved from 72% (94/131) to 82% (108/131) on a segmental basis and from 75% (27/36) to 86% (31/36) on a patient basis. Areas of uncertainty regarding nitrate-enhanced viability imaging An interesting finding in the study by He et al, and a potential caveat of the nitrate-enhanced imaging approach, was the observation that after nitrates, regional tetrofosmin uptake was actually lower in 25% of segments showing a severe perfusion defect at baseline. This paradoxical change in regional perfusion after nitrates resulted in the underestimation of viability within areas of severe perfusion deficit at baseline. The improvement in tissue perfusion after the administration of nitrovasodilators appears to result from a direct reduction in vascular resistance caused by relaxation of epicardial, arteriolar, and collateral coronary vessels and, indirectly, from a reduction in regional wall stress caused by changes in LV loading conditions that decrease tissue oxygen demand especially in the subendocardium.20 The observation of a relative reduction in regional perfusion after nitrate administration may reflect a transient redistribution of blood flow in favor of normal or nonischemic zones (so-called steal), which may undermine the ability of nitrate-enhanced imaging to detect viability in some patients. Although physiologically plausible, the frequency of this phenomenon is not clear, and its potential clinical impact warrants further investigation, particularly in patients with 3-vessel CAD who have been underrepresented or absent in this and other studies evaluating viability with the nitrate-enhanced imaging approach. This is important because patients referred for viability imaging frequently present with severe angina, dyspnea (often an angina-equivalent), or both despite maximal therapy that usually includes nitrovasodilators. This would suggest that in some patients with advanced CAD, nitrovasodilators may be unable to improve regional perfusion, and consequently, a lack of tracer uptake or an insufficient improvement in tracer uptake would not necessarily reflect the absence of clinically significant myocardial viability. Thus one should be cautious in extrapolating these results to the care of patients who are normally referred for viability imaging.
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#108
14.03.2007, 18:10
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Applicability of viability data to predictions of functional outcome
The goal of viability assessment in the setting of severe LV dysfunction after MI is to identify patients in whom revascularization can potentially improve LV function, symptoms, and survival. Then, viability assessment would be of critical clinical importance in patients with the highest clinical risk after MI (ie, LV ejection fraction <30%), who would derive the highest potential benefit from revascularization. However, more than 90% of the published data documenting the accuracy of noninvasive methods for diagnosing viability and predicting functional recovery have been obtained in patients with normal, mild, or moderate LV dysfunction (ie, LV ejection fraction >30%) (Figure 1),21 including the data in the current study by He et al. There have been only a limited number of studies with a small number of patients (representing <10% of the published data) documenting the diagnostic accuracy of methods for viability detection among patients with the highest risk.21 This is important because the accuracy of noninvasive methods for predicting functional recovery after revascularization appears to decrease significantly with worsening LV function (Figure 1). Consequently, the direct extrapolation of the excellent results obtained in patients with regional or mild to moderate LV dysfunction to patients with very low ejection fraction is problematic, and it often results in suboptimal clinical results. [Изображения доступны только зарегистрированным пользователям] Figure 1. Accuracy of methods of viability assessment for predicting a change in LV function after revascularization according to level of LV ejection fraction before revascularization. PPV, Positive predictive value; NPV, negative predictive value. This may be related in part to the fact that predictions of functional recovery after revascularization by use of noninvasive methods have been largely based solely on the extent of viable myocardium before revascularization. The focus on viability information alone seems to ignore the multifactorial influences on improvement in LV function after revascularization. From a clinical standpoint, it is likely that relying even on the most accurate of these multiple indexes of tissue viability or its absence in isolation will lead to suboptimal prediction of outcomes.22 It is now evident that multiple other factors—including the presence and magnitude of stress-induced ischemia, the stage of cellular degeneration within viable myocytes, the degree of LV remodeling, the timing and success of revascularization procedures, the adequacy of the target coronary vessels, and the timing of LV functional assessment after revascularization—can affect functional outcome after revascularization. Indeed, recent evidence suggests that integrating many of these factors influencing functional recovery after revascularization in multivariable models results in improved clinical predictions, as compared with approaches that are based only on a single index of tissue viability.23 Clinically relevant endpoints for viability imaging The study by He et al used concordance with FDG PET imaging as a surrogate endpoint to assess the diagnostic value of nitrate-enhanced imaging. Although FDG PET has been used for many years as the gold standard for viability, it is now well accepted that outcome measures such as improved survival or some measure of reduced morbidity (eg, improved symptoms, reduced hospital readmission for congestive heart failure) are needed to determine the added value of viability imaging. The published data on nitrate-enhanced imaging for detection of viability have used short-term surrogate endpoints, such as a change in regional or global LV function, to determine its clinical value.15, 16, 17, 18 Although the assumption that an improvement in LV function after revascularization would be associated with improvement in survival may often be true,24 it may not apply to all patients with low ejection fraction.25 In some patients a survival benefit from revascularization may result from improvement in blood flow to myocardial areas that are neither stunned nor hibernating but that are supplied by severely stenotic coronary arteries. Such regions might be expected to manifest stress-induced ischemia before revascularization without abnormality of resting function. Under these circumstances, revascularization of myocardium in the distribution of the severe stenoses may prevent subsequent MI and further LV remodeling, reduce life-threatening ventricular arrhythmias, and improve diastolic function, all of which will lead to improved clinical outcomes without necessarily improving resting LV function. An extensive body of literature demonstrates that patients with severe LV dysfunction, accompanied by severe angina (with or without clinical heart failure) and bypassable coronary arteries, show a survival benefit from revascularization compared with medical therapy alone.26 In this setting, however, postrevascularization improvements in survival have not been consistently associated with improvements in LV function.27 In summary, the study by He et al provides further evidence in support of the clinical usefulness of the nitrate-enhanced imaging approach for the evaluation of myocardial viability, at least in patients with moderate CAD and mild to moderate LV dysfunction. Although physiologically sound, however, the efficacy of this approach in patients with advanced CAD and severe LV dysfunction, many of whom present with progressive symptoms despite maximal medical therapy that often includes nitrovasodilators, will have to be tested in future studies. These patients represent an important segment of patients with advanced CAD and heart failure in whom viability testing is most useful. While these additional data become available, extrapolations from this and previous studies to the often difficult process of selecting patients with LV dysfunction and heart failure for high-risk revascularization procedures should be cautious. Acknowledgements The author is grateful to Ms Cynthia M. Johnson for her expert secretarial support. The author has indicated he has no financial conflicts of interest.
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#109
14.03.2007, 18:11
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References
1. Risk stratification and survival after myocardial infarction. N Engl J Med 1983;309:331-6 2. Emond M, Mock MB, Davis KB, et al. Long-term survival of medically treated patients in the Coronary Artery Surgery Study (CASS) Registry. Circulation. 1994;90:2645-2657 MEDLINE 3. Alderman EL, Fisher LD, Litwin P, et al. Results of coronary artery surgery in patients with poor left ventricular function (CASS). Circulation. 1983;68:785-795 MEDLINE 4. Bounous EP, Mark DB, Pollock BG, et al. Surgical survival benefits for coronary disease patients with left ventricular dysfunction. Circulation. 1988;78:I151-157 5. Report from the Bar Harbor conference on nuclear cardiology. J Nucl Cardiol 2001;8:224-316 6. Rahimtoola SH. The hibernating myocardium. Am Heart J. 1989;117:211-221 MEDLINE | CrossRef 7. Braunwald E, Kloner RA. The stunned myocardium: prolonged, postischemic ventricular dysfunction. Circulation. 1982;66:1146-1149 MEDLINE 8. Di Carli MF, Asgarzadie F, Schelbert HR, et al. Quantitative relation between myocardial viability and improvement in heart failure symptoms after revascularization in patients with ischemic cardiomyopathy. Circulation. 1995;92:3436-3444 MEDLINE 9. Kim RJ, Wu E, Rafael A, et al. The use of contrast-enhanced magnetic resonance imaging to identify reversible myocardial dysfunction. N Engl J Med. 2000;343:1445-1453 MEDLINE | CrossRef 10. Di Carli MF. Assessment of myocardial viability post myocardial infarction. J Nucl Cardiol. 2002;9:229-235 Abstract | Full Text | Full-Text PDF (224 KB) | MEDLINE | CrossRef 11. Bonow RO, Dilsizian V. Thallium-201 and technetium-99m-sestamibi for assessing viable myocardium. J Nucl Med. 1992;33:815-818 MEDLINE 12. Udelson JE, Coleman PS, Metherall J, et al. Predicting recovery of severe regional ventricular dysfunction. Comparison of resting scintigraphy with 201Tl and 99mTc-sestamibi. Circulation. 1994;89:2552-2561 MEDLINE 13. Bisi G, Sciagra R, Santoro GM, Zerauschek F, Fazzini PF. Sublingual isosorbide dinitrate to improve technetium-99m-teboroxime perfusion defect reversibility. J Nucl Med. 1994;35:1274-1278 MEDLINE 14. Galli M, Marcassa C, Imparato A, et al. Effects of nitroglycerin by technetium-99m sestamibi tomoscintigraphy on resting regional myocardial hypoperfusion in stable patients with healed myocardial infarction. Am J Cardiol. 1994;74:843-848 MEDLINE | CrossRef 15. Bisi G, Sciagra R, Santoro GM, Fazzini PF. Rest technetium-99m sestamibi tomography in combination with short-term administration of nitrates: feasibility and reliability for prediction of postrevascularization outcome of asynergic territories. J Am Coll Cardiol. 1994;24:1282-1289 MEDLINE 16. Maurea S, Cuocolo A, Soricelli A, et al. Enhanced detection of viable myocardium by technetium-99m-MIBI imaging after nitrate administration in chronic coronary artery disease. J Nucl Med. 1995;36:1945-1952 MEDLINE 17. Li ST, Liu XJ, Lu ZL, et al. Quantitative analysis of technetium 99m 2-methoxyisobutyl isonitrile single-photon emission computed tomography and isosorbide dinitrate infusion in assessment of myocardial viability before and after revascularization. J Nucl Cardiol. 1996;3:457-463 Abstract | Abstract + References | Full-Text PDF (1255 KB) | MEDLINE | CrossRef 18. Sciagra R, Bisi G, Santoro GM, et al. Comparison of baseline-nitrate technetium-99m sestamibi with rest-redistribution thallium-201 tomography in detecting viable hibernating myocardium and predicting postrevascularization recovery. J Am Coll Cardiol. 1997;30:384-391 MEDLINE | CrossRef 19. He W, Acampa W, Mainolfi C, et al. Tc-99m tetrofosmin tomography after nitrate administration in patients with ischemic left ventricular dysfunction: relation to metabolic imaging by PET. J Nucl Cardiol. In press 2003 20. Abrams J. Mechanism of action of the organic nitrates in the treatment of myocardial ischemia. Am J Cardiol. 1992;70:30B-42B 21. Bax JJ, Poldermans D, Elhendy A, Boersma E, Rahimtoola SH. Sensitivity, specificity, and predictive accuracies of various noninvasive techniques for detecting hibernating myocardium. Curr Probl Cardiol. 2001;26:141-186 MEDLINE 22. Di Carli MF, Hachamovitch R, Berman DS. The art and science of predicting post-revascularization improvement in LV function in patients with severely depressed LV function. J Am Coll Cardiol. 2002;40:1744-1747 Full Text | Full-Text PDF (83 KB) | MEDLINE | CrossRef 23. Beanlands RSB, Ruddy TD, deKemp RA, et al. PET and recovery following revascularization (PARR-1): the importance of scar and the development of a prediction rule for the degree of recovery of LV function. J Am Coll Cardiol. 2002;40:1735-1743 Abstract | Full Text | Full-Text PDF (277 KB) | MEDLINE | CrossRef 24. Bax JJ, Poldermans D, Elhendy A, et al. Improvement of left ventricular ejection fraction, heart failure symptoms and prognosis after revascularization in patients with chronic coronary artery disease and viable myocardium detected by dobutamine stress echocardiography. J Am Coll Cardiol. 1999;34:163-169 MEDLINE | CrossRef 25. Samady H, Elefteriades JA, Abbott BG, et al. Failure to improve left ventricular function after coronary revascularization for ischemic cardiomyopathy is not associated with worse outcome. Circulation. 1999;100:1298-1304 26. Baker DW, Jones R, Hodges J, et al. Management of heart failure. III. The role of revascularization in the treatment of patients with moderate or severe left ventricular systolic dysfunction. JAMA. 1994;272:1528-1534 MEDLINE 27. Freeman AP, Walsh WF, Giles RW, et al. Early and long-term results of coronary artery bypass grafting with severely depressed left ventricular performance. Am J Cardiol. 1984;54:749-754 MEDLINE | CrossRef a Division of Nuclear Medicine, Department of Radiology, Brigham and Women's Hospital and Harvard Medical School, Boston, Mass, USA * Reprint requests: Marcelo F. Di Carli, MD, FACC, Brigham and Women's Hospital, Division of Nuclear Medicine, 75 Francis St, Boston, MA 02115, USA doi: 10.1016/j.nuclcard.2003.09.001 © 2003 American Society of Nuclear Cardiology. Published by Elsevier Inc. All rights reserved. [Ссылки доступны только зарегистрированным пользователям ]
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#110
14.03.2007, 18:12
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[quote=Delsol- Nothing new.
[/QUOTE]Конечно, по этому методу многоцентровых исследований не проводили. Нет проблем, делайте FDG PET. Здесь тоже больных немного и проба с добутамином, но результат [Ссылки доступны только зарегистрированным пользователям ] Conclusion: This study indicated that DS SPECT correlates well with DSE in the assessment of viability. In addition, gated SPECT can evaluate regional wall motion, even in areas inadequately assessed by echocardiography. DS SPECT may also provide additional information for identifying viable myocardium, which is often overestimated by routine perfusion scans.
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#111
14.03.2007, 18:17
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А что вы думаете по поводу статьи Marcelo Di Carli? Он один из наших лучших специалистов по изотопной кардиологии. Эксперт можно сказать. И очень симпатичный человек.
 [Ссылки доступны только зарегистрированным пользователям ] [Ссылки доступны только зарегистрированным пользователям ] [Ссылки доступны только зарегистрированным пользователям ] P.S. Кстати, он с удовольствием вам ответит, если у вас есть вопросы по его статьям: [Ссылки доступны только зарегистрированным пользователям ]
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#112
14.03.2007, 18:44
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Цитата:
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#114
14.03.2007, 18:58
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Цитата:
Статья нужная, всегда полезно выслушать мнение со стороны. Да и обсуждать ее подробно здесь не получится - много разных и важных моментов. Это серьезный обзор. Очень хорошо расписан уровень захвата Tc-99m– tetrofosmin в покое. В ответ на нитроглицерин перечислены основные физиологические механизмы, но я не нашел ничего о возможном изменении счета за счет частично объемного эффекта, когда в ответ на уменьшение преднагрузки не все стенки одинаково сокращаются (а крвоток в самом миокарде может оставаться нормальным). В общем, так, на ходу, боюсь ошибиться. Я не говорю, что не хочу познакомиться, я вот и Вас не знаю. Думал, что Вы местная, но, видимо, ошибся. С уважением ОЕН.PS. Вот, например, эта ситуация This would suggest that in some patients with advanced CAD, nitrovasodilators may be unable to improve regional perfusion, and consequently, a lack of tracer uptake or an insufficient improvement in tracer uptake would not necessarily reflect the absence of clinically significant myocardial viability. Thus one should be cautious in extrapolating these results to the care of patients who are normally referred for viability imaging. может быть при полных окклюзиях, но ведь существуют еще изображения региональной функции wall motion - то, что я говорил про частично объемный эффект. В моих исследованиях у таких больных они работают.
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#116
14.03.2007, 20:22
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Цитата:
В том, что " Он человек очень доброжелательный и знаюший" я как раз не сомневаюсь.  С уважением ОЕН.
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#118
14.03.2007, 21:41
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Цитата:
По-моему, Вам как раз указали на ряд ценных моментов. Бог с ней, с правой коронарной. Не дай бог, случится рестеноз этих стентов, тогда и будет видно- насколько она важна в реваскуляризации. Гораздо важнее видится вопрос со статинами, аспирином (в данной ветке- оставшимся за кадром), и логистике действий при поражении "ствола". У Вас теперь есть шанс присмотреться к этим вопросам, и передать "тому парню", который ее писал- пару пожеланий на будушее, по доброму. ей-же-ей, пригодятся. Ведь "официальные лица", случись что- будут разглядывать зашишаемую Вами выписку гораздо более внимательно, чем здесь на форуме. А случиться, к сожалению (при таком стволе)- еще как может. И вот, скажем, (тьфу-тьфу)- приходит следствие с заплаканной вдовой, которая причитает- мол, сгубили кормильца, деньги уплОчены, артерию лечили- говорили всё будет хорошо... Или, думаете, записи об отказе об операции (если она есть в истории)- будет достаточно? А на вскрытии, положим, стенты в порядке, а та бляшешка в стволе возьми и затромбируйся. А следователь спросит- знали ли про такое поражение (а то не знали, вон сколько снимков).... А может ли оно привести к смерти (...)А почему не сделана операция, и- даже не упомянута?... И про деньги тут лучше вообше не упоминать. Хорошо, если у Вас начальство гуманное, а то как скажет- занимались самодеятельностью, не проконсультировались, да если б я знал- срочно бы на стол, вообше непонятно как прокрались в уважаемое учреждение... Это не орфография, и не формальность, это- итог работы учреждения. Больной тоже не с хр. панкреатитом поступил.И , если там нет данных нескольких пунктов- нужна ли она вообше, эта выписка.
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#119
14.03.2007, 22:32
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прошу прощение за офф...
Цитата:
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#120
15.03.2007, 02:02
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Антон, что бы Вы не сделали со стволом, все-таки пациент может помереть точно с такой же вероятностью, как если вы его - пациента со стволом - оставите в покое. Пользу реваскуларизации при стабильной стенокардии по снижению смертности еще никому не удалось доказать (а уж сколько народу пыталось - не перечесть), за исключением случаев многососудистого поражения со сниженной фракцией выброса.
Занимаемся мы по большей части косметикой и симптоматикой согласно гайдов. Пользу определения жизнеспособности тоже доказать никому еще не удалось. Все это на уровне научных домыслов. Единственный параметр, который доказано определяет смертность как известно только один - фракция выброса. По поводу влияния инсулина исследования все- таки были. У меня вот на полке стоит первое издание Джослина после Баттинга с Бэстом. Очень интересные наблюдения влияния инсулина на смертность пациентов с диабетом первого типа. Эффект значительно выражен - 1000% относительное снижение риска смерти NNT=1 (меньше не бывает). Для сравнения любимая писиайка NNT 20 от силы при ACS (как тут выражались намечается тернд).
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Линейный вид
