Ciampi Quirino, Rigo Fausto, Grolla Elisabetta, Picano Eugenio, Cortigiani Lauro
Division of Cardiology, Fatebenefratelli Hospital, Viale Principe di Napoli, 12 I-82100, Benevento, Italy.
CNR Institute of Clinical Physiology, Pisa, Italy.
Cardiovasc Ultrasound. 2015 Apr 21;13:21. doi: 10.1186/s12947-015-0013-8.
Dual imaging stress echocardiography, combining the evaluation of wall motion and coronary flow reserve (CFR) on the left anterior descending artery (LAD), and computed tomography coronary angiography (CTCA) are established techniques for assessing prognosis in chest pain patients. In this study we compared the prognostic value of the two methods in a cohort of patients with chest pain having suspected coronary artery disease (CAD).
A total of 131 patients (76 men; age 68 ± 9 years) with chest pain of unknown origin underwent dipyridamole (up to 0.84 mg/kg over 6 min) stress echo with CFR assessment of LAD by Doppler and CTCA. A CFR ≤ 1.9 was considered abnormal, while > 50% lumen diameter reduction was the criterion for significant CAD at CTCA.
Of 131 patients, 34 (26%) had ischemia at stress echo (new wall motion abnormalities), and 56 (43%) had reduced CFR on LAD. Significant coronary stenosis at CTCA was found in 69 (53%) patients. Forty-six patients (84%) with abnormal CFR on LAD showed significant CAD at CTCA (p < 0.001). Calcium score was higher in patients with reduced than in those with normal CFR (265 ± 404 vs 131 ± 336, p = 0.04). During a median follow-up of 7 months (1st to 3rd quartile: 5-13 months), there were 45 major cardiac events (4 deaths, 11 nonfatal myocardial infarctions, and 30 late [≥6 months] coronary revascularizations). At Cox analysis, independent prognostic indicators were calcium score > 100 (HR 2.84, 95% CI 1.33-6.07, p = 0.007), significant CAD at CTCA (HR 2.68, 95% CI 1.23-5.82, p = 0.013), and inducible ischemia or CFR <1.9R on LAD on dual imaging stress echo (HR 2.25, 95% CI 1.05-4.84, p = 0.038).
Functional and anatomical evaluation using, respectively, dual imaging stress echocardiography and CTCA are both effective modalities to risk stratify patients with chest pain of unknown origin, yielding independent and comparable prognostic value. Compared to CTCA, however, stress echocardiography has the advantage of lower cost and of being free of radiations.
双成像负荷超声心动图结合左前降支（LAD）壁运动及冠状动脉血流储备（CFR）评估与计算机断层扫描冠状动脉造影（CTCA）是评估胸痛患者预后的成熟技术。在本研究中，我们比较了这两种方法在一组疑似冠心病（CAD）胸痛患者中的预后价值。
总共131例（76例男性；年龄68±9岁）不明原因胸痛患者接受了双嘧达莫（6分钟内最大剂量0.84mg/kg）负荷超声心动图检查，通过多普勒评估LAD的CFR，并进行CTCA检查。CFR≤1.9被认为异常，而CTCA中管腔直径减少>50%是显著CAD的标准。
131例患者中，34例（26%）在负荷超声心动图时有心肌缺血（新的壁运动异常），56例（43%）LAD的CFR降低。CTCA显示69例（53%）患者有显著冠状动脉狭窄。LAD的CFR异常的46例患者（84%）在CTCA时显示有显著CAD（p<0.001）。CFR降低的患者的钙评分高于CFR正常的患者（265±404 vs 131±336，p=0.04）。在中位随访7个月（第1至第3四分位数：5 - 13个月）期间，发生了45次主要心脏事件（4例死亡、11例非致命性心肌梗死和30例晚期[≥6个月]冠状动脉血运重建）。在Cox分析中，独立的预后指标是钙评分>100（HR 2.84，95%CI 1.33 - 6.07，p = 0.007）、CTCA显示有显著CAD（HR 2.68，95%CI 1.23 - 5.82，p = 0.013）以及双成像负荷超声心动图时LAD上可诱导的心肌缺血或CFR<1.9R（HR 2.25，95%CI 1.05 - 4.84，p = 0.038）。
分别使用双成像负荷超声心动图和CTCA进行功能和解剖学评估都是对不明原因胸痛患者进行危险分层的有效方法，具有独立且可比的预后价值。然而，与CTCA相比，负荷超声心动图具有成本较低且无辐射的优势。
