CT 血管造影对急诊科急性胸痛患者主要不良心脏事件的预后价值：ROMICAT 试验的 2 年结果。
Prognostic value of CT angiography for major adverse cardiac events in patients with acute chest pain from the emergency department: 2-year outcomes of the ROMICAT trial.
机构信息
Cardiac MR PET CT Program, Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA.
出版信息
JACC Cardiovasc Imaging. 2011 May;4(5):481-91. doi: 10.1016/j.jcmg.2010.12.008.
OBJECTIVES
The aim of this study was to determine the 2-year prognostic value of cardiac computed tomography (CT) for predicting major adverse cardiac events (MACE) in patients presenting to the emergency department (ED) with acute chest pain.
BACKGROUND
CT has high potential for early triage of acute chest pain patients. However, there is a paucity of data regarding the prognostic value of CT in this ED cohort.
METHODS
We followed 368 patients from the ROMICAT (Rule Out Myocardial Infarction Using Computer Assisted Tomography) trial (age 53 ± 12 years; 61% male) who presented to the ED with acute chest pain, negative initial troponin, and a nonischemic electrocardiogram for 2 years. Contrast-enhanced 64-slice CT was obtained during index hospitalization, and caregivers and patients remained blinded to the results. CT was assessed for the presence of plaque, stenosis (>50% luminal narrowing), and left ventricular regional wall motion abnormalities (RWMA). The primary endpoint was MACE, defined as composite cardiac death, nonfatal myocardial infarction, or coronary revascularization.
RESULTS
Follow-up was completed in 333 patients (90.5%) with a median follow-up period of 23 months. At the end of the follow-up period, 25 patients (6.8%) experienced 35 MACE (no cardiac deaths, 12 myocardial infarctions, and 23 revascularizations). Cumulative probability of 2-year MACE increased across CT strata for coronary artery disease (CAD) (no CAD 0%; nonobstructive CAD 4.6%; obstructive CAD 30.3%; log-rank p < 0.0001) and across combined CT strata for CAD and RWMA (no stenosis or RWMA 0.9%; 1 feature-either RWMA [15.0%] or stenosis [10.1%], both stenosis and RWMA 62.4%; log-rank p < 0.0001). The c statistic for predicting MACE was 0.61 for clinical Thrombolysis In Myocardial Infarction risk score and improved to 0.84 by adding CT CAD data and improved further to 0.91 by adding RWMA (both p < 0.0001).
CONCLUSIONS
CT coronary and functional features predict MACE and have incremental prognostic value beyond clinical risk score in ED patients with acute chest pain. The absence of CAD on CT provides a 2-year MACE-free warranty period, whereas coronary stenosis with RWMA is associated with the highest risk of MACE.
目的
本研究旨在确定心脏计算机断层扫描（CT）对急诊科（ED）因急性胸痛就诊的患者预测主要不良心脏事件（MACE）的 2 年预后价值。
背景
CT 对急性胸痛患者的早期分诊有很大的潜力。然而，关于 ED 患者 CT 预后价值的数据却很少。
方法
我们对来自 ROMICAT（使用计算机辅助 CT 排除心肌梗死）试验的 368 例患者进行了随访（年龄 53 ± 12 岁；61%为男性），这些患者因急性胸痛、初始肌钙蛋白阴性和非缺血性心电图在 ED 就诊。在住院期间进行了对比增强 64 排 CT 检查，医护人员和患者对结果均保持盲态。CT 用于评估斑块、狭窄（管腔狭窄>50%）和左心室局部壁运动异常（RWMA）的存在。主要终点是 MACE，定义为复合性心源性死亡、非致死性心肌梗死或冠状动脉血运重建。
结果
333 例患者（90.5%）完成了随访，中位随访时间为 23 个月。在随访结束时，25 例患者（6.8%）发生了 35 例 MACE（无心脏死亡、12 例心肌梗死和 23 例血运重建）。根据 CT 冠状动脉疾病（CAD）分层，2 年 MACE 的累积概率呈递增趋势（无 CAD 0%；非阻塞性 CAD 4.6%；阻塞性 CAD 30.3%；对数秩检验 p<0.0001）；根据 CAD 和 RWMA 的综合 CT 分层，2 年 MACE 的累积概率也呈递增趋势（无狭窄或 RWMA 0.9%；有 1 个特征-要么 RWMA[15.0%]，要么狭窄[10.1%]，两者都狭窄和 RWMA 62.4%；对数秩检验 p<0.0001）。预测 MACE 的 c 统计量为临床溶栓治疗心肌梗死风险评分的 0.61，增加 CT CAD 数据后提高至 0.84，进一步增加 RWMA 后提高至 0.91（均 p<0.0001）。
结论
CT 冠状动脉和功能特征预测 MACE，在 ED 因急性胸痛就诊的患者中，其预后价值优于临床风险评分。CT 未见 CAD 可提供 2 年无 MACE 的保证期，而有冠状动脉狭窄伴 RWMA 与最高的 MACE 风险相关。
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