Duke Clinical Research Institute, Duke University, Durham, NC.
Duke Clinical Research Institute, Duke University, Durham, NC.
Am Heart J. 2014 Jun;167(6):846-52.e2. doi: 10.1016/j.ahj.2014.03.001. Epub 2014 Mar 14.
Guidelines recommend noninvasive tests (NITs) to risk stratify and identify patients with higher likelihood of coronary artery disease (CAD) prior to elective coronary angiography. However, a high percentage of patients are found to have nonobstructive CAD. We aimed to understand the relationship between patient characteristics, NIT findings, and the likelihood of nonobstructive CAD.
Patients undergoing elective catheterization without history of CAD were identified from 1,128 hospitals in National Cardiovascular Data Registry's CathPCI Registry between July 2009 and December 2011. Noninvasive tests included stress electrocardiogram, stress echocardiogram, stress radionuclide, stress cardiac magnetic resonance, and computed tomographic angiography. Patient demographics, risk factors, symptoms, and NIT results were correlated with the presence of nonobstructive CAD, defined as all native coronary stenoses <50%.
Of 661,063 patients undergoing elective angiography, 386,003 (58.4%) had nonobstructive CAD. Preprocedure NIT was performed in 64% of patients; 51.9% were reported to be abnormal, but only 9% had high-risk findings. Independent factors associated with nonobstructive CAD were younger age, female sex, atypical chest pain, and a low-risk NIT. Patients with high-risk findings on NIT were more likely to have obstructive CAD (adjusted odds ratio 3.03 [2.86-3.22]). Noninvasive test findings had minimal incremental value beyond clinical factors for predicting obstructive disease (C index = 0.75 for clinical factors vs 0.74 for NIT findings).
In current practice, about two-thirds of patients undergo NIT prior to elective cardiac catheterization, yet most patients have nonobstructive CAD. The weak correlation between most NIT results and the likelihood of obstructive CAD provides further impetus for improving preangiography assessment of likelihood of disease.
指南建议使用非侵入性检查（NIT）对择期冠状动脉造影前的患者进行危险分层和识别，以确定其更有可能患有冠状动脉疾病（CAD）。然而，仍有很大一部分患者被发现患有非阻塞性 CAD。我们旨在了解患者特征、NIT 检查结果与非阻塞性 CAD 可能性之间的关系。
从 2009 年 7 月至 2011 年 12 月，国家心血管数据注册中心的 CathPCI 注册中心在 1128 家医院中确定了无 CAD 病史的择期行导管插入术的患者。非侵入性检查包括运动心电图、运动超声心动图、运动放射性核素、运动心脏磁共振和计算机断层血管造影。患者人口统计学、危险因素、症状和 NIT 结果与非阻塞性 CAD 的存在相关，定义为所有原生冠状动脉狭窄<50%。
在接受择期血管造影的 661,063 例患者中，386,003 例（58.4%）患有非阻塞性 CAD。64%的患者在术前进行了 NIT；51.9%的报告异常，但只有 9%的患者有高危发现。与非阻塞性 CAD 相关的独立因素包括年龄较小、女性、非典型胸痛和低风险 NIT。NIT 有高危发现的患者更有可能患有阻塞性 CAD（调整后的优势比为 3.03[2.86-3.22]）。NIT 检查结果对预测阻塞性疾病的临床因素的增量价值很小（C 指数为 0.75 用于临床因素，0.74 用于 NIT 结果）。
在目前的实践中，大约三分之二的患者在择期心脏导管插入术前行 NIT，但大多数患者患有非阻塞性 CAD。大多数 NIT 结果与阻塞性 CAD 可能性之间的弱相关性进一步推动了改善血管造影前疾病可能性评估。
