Rubinshtein Ronen, Halon David A, Gaspar Tamar, Jaffe Ronen, Goldstein Jacob, Karkabi Basheer, Flugelman Moshe Y, Kogan Asia, Shapira Reuma, Peled Nathan, Lewis Basil S
Department of Cardiovascular Medicine, Lady Davis Carmel Medical Center and Ruth and Bruce Rappaport School of Medicine, Technion-Israel Institute of Technology, Haifa, Israel.
Am J Cardiol. 2007 Nov 15;100(10):1522-6. doi: 10.1016/j.amjcard.2007.06.052. Epub 2007 Sep 27.
To examine the impact of contrast enhanced multidetector computed tomography (MDCT) on clinical decision-making in patients who present to the emergency department (ED) with chest pain of possible ischemic origin, we studied 58 consecutive patients (age 56 +/- 10 years, 36% female) with chest pain, intermediate risk, and no ischemic electrocardiographic changes or increased biomarker measurements. After standard ED patient assessment including cardiology consultation, a diagnosis of acute coronary syndrome was made in 41 patients (71%), hospitalization was recommended in 47 (81%), and 32 (55%) were scheduled for an early invasive strategy. Patients underwent 64-slice contrast agent-enhanced MDCT with image reconstruction in multiple formats using retrospective electrocardiographic gating, which revealed normal (no or trivial atheroma) coronary vasculature in 15 patients, nonobstructive atheroma in 20 patients, and obstructive coronary disease (> or =1 luminal narrowing of > or =50%) in 23 patients. After MDCT, the diagnosis of acute coronary syndrome was revised in 18 of 41 patients (44%; 16 normal MDCT/widely patent stents, 2 alternative diagnoses), planned hospitalization canceled in 21 of 47 patients (45%; 13 normal MDCT/patent stent, 8 minor branch vessel disease), and planned early invasive strategy altered in 25 of 58 patients (43%; unnecessary in 20 of 32, advisable in 5 of 26 others). Effect of MDCT on clinical decisions was greater in the 36 patients without known preceding coronary disease. In 32 patients discharged from the ED (11 after initial triage, 21 patients after MDCT), there were no major adverse cardiac events (e.g., death, myocardial infarction, unplanned revascularization) during a 12-month follow-up period. In conclusion, contrast agent-enhanced 64-slice cardiac MDCT was a valuable diagnostic tool in the ED triage of patients with chest pain of possible ischemic origin and decreased the need for hospitalization by almost half in this patient cohort.
为了研究对比增强多层螺旋计算机断层扫描（MDCT）对因可能源于缺血性胸痛而就诊于急诊科（ED）的患者临床决策的影响，我们对58例连续的患者（年龄56±10岁，36%为女性）进行了研究，这些患者有胸痛症状、处于中度风险且无缺血性心电图改变或生物标志物测量值升高。在包括心内科会诊在内的标准急诊科患者评估后，41例患者（71%）被诊断为急性冠状动脉综合征，47例（81%）被建议住院，32例（55%）被安排采取早期侵入性策略。患者接受了64层对比剂增强MDCT检查，并使用回顾性心电图门控以多种格式进行图像重建，结果显示15例患者冠状动脉血管正常（无或仅有轻微动脉粥样硬化），20例患者有非阻塞性动脉粥样硬化，23例患者有阻塞性冠状动脉疾病（≥1处管腔狭窄≥50%）。MDCT检查后，41例患者中有18例（44%；16例MDCT正常/支架通畅，2例为其他诊断）急性冠状动脉综合征的诊断被修订，47例患者中有21例（45%；13例MDCT正常/支架通畅，8例为小分支血管疾病）取消了计划中的住院，58例患者中有25例（43%；32例中的20例无需进行，另外26例中的5例建议进行）计划中的早期侵入性策略发生改变。MDCT对无已知既往冠状动脉疾病的36例患者的临床决策影响更大。在32例从急诊科出院的患者中（11例在初始分诊后，21例在MDCT检查后），在12个月的随访期内无重大不良心脏事件（如死亡、心肌梗死、非计划血管重建）。总之，对比剂增强64层心脏MDCT是对可能源于缺血性胸痛患者进行急诊科分诊的有价值的诊断工具，并使该患者队列中的住院需求减少了近一半。
