Roguin Ariel, Abadi Sobhi, Ghersin Eduard, Engel Ahuva, Beyar Rafael, Rispler Shmuel
Department of Cardiology, Rambam Medical Center, Haifa, Israel.
Isr Med Assoc J. 2008 Oct;10(10):702-6.
Multi-detector computed tomography has advanced enormously and now enables non-invasive evaluation of coronary arteries as well as cardiac anatomy, function and perfusion. However, the role of cardiac MDCT is not yet determined in the medical community and, consequently, many clinically unnecessary scans are performed solely on a self-referral basis.
To prospectively evaluate the role of a cardiologist consultation and recommendation prior to the scan, and the influence on the diagnostic yield of cardiac MDCT.
In our center a CT service was initiated, but with the prerequisite approval of a cardiologist before performance of the CT. Each individual who wanted and was willing to pay for a cardiac CT was interviewed by an experienced cardiologist who determined whether cardiac MDCT was the most appropriate next test in the cardiovascular evaluation. Subjects were classified into three groups: a) those with a normal or no prior stress test, no typical symptoms and no significant risk factors of coronary artery disease were recommended to perform a stress test or to remain under close clinical follow-up without MDCT; b) those with an equivocal stress test, atypical symptoms and/or significant risk factors were allowed to have cardiac MDCT; and c) those with positive stress test or clinically highly suspected CAD were advised to go directly to invasive coronary angiography. CT findings were categorized as normal CAD (normal calcium score and no narrowings), < 50% and > 50% CAD.
A total of 254 people were interviewed, and in only 39 cases did the cardiologist approve the CT. However, 61 of the 215, despite our recommendation not to undergo CT, decided to have the scan. Assessment of the 100 cases that underwent MDCT showed a statistically significant better discrimination of significant CAD, according to the cardiologist's recommendation: MDCT not recommended in 3/54 (6%) vs. MDCT recommended in 12/39 (31%) vs. recommended invasive coronary angiography in 4/7 (57%)(P<0.001).
Detection of coronary calcification, as well as MDCT angiography can provide clinically useful information if applied to suitable patient groups. It is foreseeable that MDCT angiography will become part of the routine workup in some subsets of patients with suspected CAD. Selection of patients undergoing MDCT scans by a cardiologist improves the ability of the test to stratify patients, preventing unnecessary scans in both high and low risk patients.
多排螺旋计算机断层扫描技术已取得巨大进展，如今能够对冠状动脉以及心脏解剖结构、功能和灌注进行无创评估。然而，心脏多排螺旋CT在医学界的作用尚未确定，因此，许多临床上不必要的扫描仅仅是基于患者的自行要求进行的。
前瞻性评估在扫描前进行心脏病专家会诊和建议的作用，以及对心脏多排螺旋CT诊断率的影响。
在我们中心启动了一项CT服务，但在进行CT之前需要心脏病专家的预先批准。每位想要并愿意支付心脏CT费用的个体均由一位经验丰富的心脏病专家进行访谈，该专家会确定心脏多排螺旋CT是否是心血管评估中最合适的下一步检查。受试者被分为三组：a）那些既往应激试验正常或未进行过应激试验、没有典型症状且没有冠状动脉疾病显著危险因素的患者，建议进行应激试验或在不进行多排螺旋CT的情况下接受密切临床随访；b）那些应激试验结果不明确、有非典型症状和/或显著危险因素的患者，可以进行心脏多排螺旋CT检查；c）那些应激试验阳性或临床上高度怀疑患有冠心病的患者，建议直接进行有创冠状动脉造影。CT检查结果分为正常冠心病（钙化评分正常且无狭窄）、<50%冠心病和>50%冠心病。
共对254人进行了访谈，只有39例患者经心脏病专家批准进行CT检查。然而，在215例患者中，有61例尽管我们建议不要进行CT检查，但他们仍决定进行扫描。根据心脏病专家的建议，对接受多排螺旋CT检查的100例患者进行评估，结果显示对显著冠心病的鉴别具有统计学意义上的更好效果：不建议进行多排螺旋CT检查的患者中3/54（6%），建议进行多排螺旋CT检查的患者中12/39（31%），建议进行有创冠状动脉造影的患者中4/7（57%）（P<0.001）。
如果应用于合适的患者群体，冠状动脉钙化检测以及多排螺旋CT血管造影可以提供临床有用信息。可以预见，多排螺旋CT血管造影将成为某些疑似冠心病患者亚组常规检查的一部分。由心脏病专家选择进行多排螺旋CT扫描的患者可提高该检查对患者进行分层的能力，避免在高风险和低风险患者中进行不必要的扫描。
