Department of Radiology, Thomas Jefferson University, Philadelphia, PA 19107-5244, USA.
Acad Radiol. 2010 May;17(5):577-86. doi: 10.1016/j.acra.2009.12.015. Epub 2010 Feb 20.
The aim of this study was to apply a decision analytic model for the evaluation of coronary artery disease (CAD) to define the optimal utilization of coronary computed tomographic angiography (cCTA) and stress testing.
The model tested in this study assumes that CAD is evaluated with a stress test and/or cCTA and that a patient with positive evaluation results undergoes cardiac catheterization. On the basis of values of sensitivity, specificity, and radiation dose from the published literature and test costs from the Medicare fee schedule, a decision tree model was constructed as a function of disease prevalence.
The false-negative rate is lowest when cCTA is used as an isolated test. The false-positive rate is minimized when cCTA is used in combination with stress echocardiography. Effective radiation is minimized by use of stress electrocardiography or stress echocardiography alone or prior to cCTA. When the pretest probability of CAD is low, a strategy that uses stress echocardiography followed by cCTA minimizes the false-positive rate and effective radiation exposure, with relatively low imaging costs and with a false-negative rate only slightly higher than a strategy including stress myocardial scintigraphy. As the pretest probability of CAD increases above 20%, the false-negative rate of stress echocardiography followed by cCTA increases by >5% relative to cCTA alone.
Effective radiation dose and imaging costs for the workup of CAD may be minimized by an appropriate combination of stress testing and cCTA. A strategy that uses stress echocardiography followed by cCTA is most appropriate for the evaluation of low-risk patients with CAD with a pretest probability < 20%, while cCTA alone may be more appropriate in intermediate-risk patients.
本研究旨在应用用于评估冠心病（CAD）的决策分析模型来确定冠状动脉计算机断层扫描血管造影（cCTA）和应激测试的最佳使用方法。
本研究中测试的模型假设使用应激测试和/或 cCTA 来评估 CAD，并且具有阳性评估结果的患者接受了心脏导管插入术。基于从已发表的文献中获得的敏感性、特异性和辐射剂量值以及医疗保险费用表中的测试成本，构建了一个决策树模型，该模型是疾病流行率的函数。
当仅使用 cCTA 作为单独的测试时，假阴性率最低。当 cCTA 与超声心动图应激测试联合使用时，假阳性率最低。单独使用或在进行 cCTA 之前使用应激心电图或超声心动图可以将有效辐射降至最低。当 CAD 的术前概率较低时，使用超声心动图应激测试随后进行 cCTA 的策略可将假阳性率和有效辐射暴露降至最低，同时成像成本相对较低，假阴性率仅略高于包括应激心肌闪烁显像的策略。当 CAD 的术前概率高于 20%时，超声心动图应激测试随后进行 cCTA 的策略的假阴性率相对于单独使用 cCTA 增加了>5%。
通过适当组合应激测试和 cCTA，可以使 CAD 检查的有效辐射剂量和成像成本最小化。对于术前概率<20%的低危 CAD 患者，使用超声心动图应激测试随后进行 cCTA 的策略最为合适，而对于中危患者，单独使用 cCTA 可能更为合适。
