稳定性心绞痛：心脏 CT 和运动试验预后价值的头对头比较。

Stable angina pectoris: head-to-head comparison of prognostic value of cardiac CT and exercise testing.

机构信息

Department of Cardiology, Erasmus University Medical Centre, 's-Gravendijkwal 230, PO Box 2040, 3000 CA Rotterdam, The Netherlands.

出版信息

Radiology. 2011 Nov;261(2):428-36. doi: 10.1148/radiol.11110744. Epub 2011 Aug 24.

DOI:10.1148/radiol.11110744

PMID:21873254

Abstract

PURPOSE

To determine and compare the prognostic value of cardiac computed tomographic (CT) angiography, coronary calcium scoring, and exercise electrocardiography (ECG) in patients with chest pain who are suspected of having coronary artery disease (CAD).

MATERIALS AND METHODS

This study complied with the Declaration of Helsinki, and the local ethics committee approved the study. Patients (n = 471) without known CAD underwent exercise ECG and dual-source CT at a rapid assessment outpatient chest pain clinic. Coronary calcification and the presence of 50% or greater coronary stenosis (in one or more vessels) were assessed with CT. Exercise ECG results were classified as normal, ischemic, or nondiagnostic. The primary outcome was a major adverse cardiac event (MACE), defined as cardiac death, nonfatal myocardial infarction, or unstable angina requiring hospitalization and revascularization beyond 6 months. Univariable and multivariable Cox regression analysis was used to determine the prognostic values, while clinical impact was assessed with the net reclassification improvement metric.

RESULTS

Follow-up was completed for 424 (90%) patients; the mean duration of follow-up was 2.6 years. A total of 44 MACEs occurred in 30 patients. Four of the MACEs were cardiac deaths and six were nonfatal myocardial infarctions. The presence of coronary calcification (hazard ratio [HR], 8.22 [95% confidence interval {CI}: 1.96, 34.51]), obstructive CAD (HR, 6.22 [95% CI: 2.77, 13.99]), and nondiagnostic stress test results (HR, 3.00 [95% CI: 1.26, 7.14]) were univariable predictors of MACEs. In the multivariable model, CT angiography findings (HR, 5.0 [95% CI: 1.7, 14.5]) and nondiagnostic exercise ECG results (HR, 2.9 [95% CI: 1.2, 7.0]) remained independent predictors of MACEs. CT angiography findings showed incremental value beyond clinical predictors and stress testing (global χ(2), 37.7 vs 13.7; P < .001), whereas coronary calcium scores did not have further incremental value (global χ(2), 38.2 vs 37.7; P = .40).

CONCLUSION

CT angiography findings are a strong predictor of future adverse events, showing incremental value over clinical predictors, stress testing, and coronary calcium scores.

SUPPLEMENTAL MATERIAL

http://radiology.rsna.org/lookup/suppl/doi:10.1148/radiol.11110744/-/DC1.

摘要

目的

确定并比较心脏 CT 血管造影术、冠状动脉钙化评分和运动心电图在疑似患有冠状动脉疾病（CAD）的胸痛患者中的预后价值。

材料和方法

本研究符合赫尔辛基宣言，当地伦理委员会批准了该研究。在快速评估门诊胸痛诊所，对 471 名无已知 CAD 的患者进行运动心电图和双源 CT 检查。使用 CT 评估冠状动脉钙化和 50%或更大冠状动脉狭窄（一条或多条血管）的存在情况。将运动心电图结果分为正常、缺血或无法诊断。主要终点是主要不良心脏事件（MACE），定义为心脏死亡、非致命性心肌梗死或不稳定型心绞痛，需要在 6 个月后进行血管重建。采用单变量和多变量 Cox 回归分析确定预后价值，同时使用净重新分类改善指标评估临床影响。

结果

424 名（90%）患者完成了随访；平均随访时间为 2.6 年。30 名患者共发生 44 例 MACE，其中 4 例为心脏死亡，6 例为非致命性心肌梗死。冠状动脉钙化存在（危险比 [HR]，8.22 [95%置信区间 {CI}：1.96，34.51]）、阻塞性 CAD（HR，6.22 [95% CI：2.77，13.99]）和运动试验结果无法诊断（HR，3.00 [95% CI：1.26，7.14]）是 MACE 的单变量预测因子。在多变量模型中，CT 血管造影检查结果（HR，5.0 [95% CI：1.7，14.5]）和运动心电图结果无法诊断（HR，2.9 [95% CI：1.2，7.0]）仍然是 MACE 的独立预测因子。CT 血管造影检查结果显示，其预后价值超过临床预测因素和应激试验（整体 χ(2)，37.7 比 13.7；P <.001），而冠状动脉钙评分没有进一步的增量价值（整体 χ(2)，38.2 比 37.7；P =.40）。