Murray Gary L
Director Medical Research, Heart and Vascular Institute, Germantown, Tennessee.
Int J Angiol. 2014 Sep;23(3):165-70. doi: 10.1055/s-0034-1382290.
Normal myocardial perfusion imaging (MPI) reduces intermediate- or high-risk pretest probability patients to low- or intermediate-risk posttest probability, respectively, for coronary disease (CD). Since ranolazine (RAN) relieves only angina, anginal patients with normal MPI whose angina is relieved by RAN present a significant dilemma. The purpose of this retrospective chart review was to confirm the impression that coronary angiography (CA) is indicated in patients whose class 3 to 4 angina is relieved by RAN, but have normal myocardial single-photon emission computed tomography (SPECT) MPIs. Charts of patients with stable class 3 to 4 angina (typical and atypical) and normal MPIs (left ventricular ejection fraction [LVEF] ≥50% and segmental score = 0) were reviewed. CA was done on all the patients with complete angina relief taking RAN, as well as nonresponders whose anginal etiology could not be explained. Stenoses were considered flow-restrictive when more than 70% diameter stenosis is observed by quantitative CA, or, when 50 to 70%, fractional flow reserve (FFR) measured ≤0.80. RAN relieved angina in 36 of 54 (67%) patients. Of the known cases, 25 of these 36 (69%) had 43 stenoses ≥50% (mean = 66%): 15 (60%) had 1 vessel disease; 9 (36%) had multivessel disease; 18 (72%) had left anterior descending (LAD) disease; 1 (4%) had left main disease. Twenty one of 43 (49%) stenosis were > 70%; 22 (51%) stenoses were 50 to 70% and required FFR measurement. Twenty nine of 43 stenoses (67%) were considered flow-restrictive in 18 of these 25 (72%) patients. Eight RAN nonresponders with no explanation for angina had no CD at CA. RAN angina relief is invaluable in identifying falsely negative SPECT MPI, and 50% of these patients have flow-restrictive stenoses.
正常心肌灌注成像（MPI）可分别将冠心病（CD）中、高风险的检测前概率患者降低至低风险或中风险的检测后概率。由于雷诺嗪（RAN）仅能缓解心绞痛，对于MPI正常且心绞痛可被RAN缓解的心绞痛患者而言，这是一个重大难题。本回顾性病历审查的目的是证实以下观点：对于3至4级心绞痛经RAN缓解但心肌单光子发射计算机断层扫描（SPECT）MPI正常的患者，冠状动脉造影（CA）是必要的。对稳定型3至4级心绞痛（典型和非典型）且MPI正常（左心室射血分数[LVEF]≥50%且节段评分=0）的患者病历进行了审查。对所有服用RAN后心绞痛完全缓解的患者以及心绞痛病因无法解释的无反应者均进行了CA检查。当定量CA观察到直径狭窄超过70%，或狭窄50%至70%时，血流储备分数（FFR）测量≤0.80，则认为狭窄具有血流限制性。54例患者中有36例（67%）的心绞痛被RAN缓解。在已知病例中，这36例中的25例（69%）有43处狭窄≥50%（平均=66%）：15例（60%）为单支血管病变；9例（36%）为多支血管病变；18例（72%）有左前降支（LAD）病变；1例（4%）有左主干病变。43处狭窄中有21处（49%）＞70%；22处（51%）狭窄为50%至70%，需要测量FFR。43处狭窄中有29处（67%）在这25例患者中的18例（72%）中被认为具有血流限制性。8例对RAN无反应且心绞痛无法解释的患者在CA检查中未发现冠心病。RAN缓解心绞痛对于识别SPECT MPI假阴性非常重要，这些患者中有50%存在血流限制性狭窄。
