Pontone Gianluca, Andreini Daniele, Guaricci Andrea I, Rota Cristina, Guglielmo Marco, Mushtaq Saima, Baggiano Andrea, Beltrama Virginia, Fusini Laura, Solbiati Anna, Segurini Chiara, Conte Edoardo, Gripari Paola, Annoni Andrea, Formenti Alberto, Petulla' Maria, Lombardi Federico, Muscogiuri Giuseppe, Bartorelli Antonio L, Pepi Mauro
From the Centro Cardiologico Monzino, IRCCS, Milan, Italy (G.P., D.A., C.R., M.G., S.M., A.B., V.B., L.F., A.S., C.S., E.C., P.G., A.A., A.F., M.P., A.L.B., M.P.); Department of Cardiovascular Sciences and Community Health, University of Milan, Italy (D.A., C.R., A.B., A.S., C.S., F.L.); Institute of Cardiovascular Disease, Department of Emergency and Organ Transplantation, University Hospital "Policlinico Consorziale" of Bari, Italy (A.I.G.); Department of Medical and Surgical Sciences, University of Foggia, Italy (A.I.G.); UOC Malattie Cardiovascolari, Fondazione IRCCS Ospedale Maggiore Policlinico, Milan, Italy (F.L.); and Department of Imaging, Bambino Gesù-Children's Hospital IRCCS, Rome, Italy (G.M.); Department of Biomedical and Clinical Sciences "Luigi Sacco," University of Milan, Italy (A.L.B.).
Circ Cardiovasc Imaging. 2016 Oct;9(10). doi: 10.1161/CIRCIMAGING.116.005171.
Computed tomography coronary angiography (cTCA) and stress cardiac magnetic resonance (stress-CMR) are suitable tools for diagnosing obstructive coronary artery disease in symptomatic patients with previous history of revascularization. However, performance appraisal of noninvasive tests must take in account the consequent diagnostic testing, invasive procedures, clinical outcomes, radiation exposure, and cumulative costs rather than their diagnostic accuracy only. We aimed to compare an anatomic (cTCA) versus a functional (stress-CMR) strategy in symptomatic patients with previous myocardial revascularization procedures.
Six hundred patients with chest pain and previous revascularization included in a prospective observational registry and evaluated by clinically indicated cTCA (n=300, mean age 68.2±9.7 years, male 255) or stress-CMR (n=300, mean age 67.6±9.7 years, male 263) were enrolled and followed-up in terms of subsequent noninvasive tests, invasive coronary angiography, revascularization procedures, cumulative effective radiation dose, major adverse cardiac events, defined as a composite end point of nonfatal myocardial infarction and cardiac death, and medical costs. The mean follow-up for cTCA and stress-CMR groups was similar (773.6±345 versus 752.8±291 days; P=0.21). Compared with stress-CMR, cTCA was associated with a higher rate of subsequent noninvasive tests (28% versus 17%; P=0.0009), invasive coronary angiography (31% versus 20%; P=0.0009), and revascularization procedures (24% versus 16%; P=0.007). Stress-CMR strategy was associated with a significant reduction of radiation exposure and cumulative costs (59% and 24%, respectively; P<0.001). Finally, patients undergoing stress-CMR showed a lower rate of major adverse cardiac events (5% versus 10%; P<0.010) and cost-effectiveness ratio (119.98±250.92 versus 218.12±298.45 Euro/y; P<0.001).
Compared with cTCA, stress-CMR is more cost-effective in symptomatic revascularized patients.
计算机断层扫描冠状动脉造影（cTCA）和应力心脏磁共振成像（stress-CMR）是诊断有血运重建史的有症状患者阻塞性冠状动脉疾病的合适工具。然而，无创检查的性能评估必须考虑后续的诊断测试、侵入性操作、临床结果、辐射暴露和累积成本，而不仅仅是其诊断准确性。我们旨在比较有心肌血运重建史的有症状患者的解剖学（cTCA）与功能性（stress-CMR）策略。
600例有胸痛且有血运重建史的患者纳入前瞻性观察登记研究，接受临床指征的cTCA（n = 300，平均年龄68.2±9.7岁，男性255例）或stress-CMR（n = 300，平均年龄67.6±9.7岁，男性263例）评估，并就后续无创检查、侵入性冠状动脉造影、血运重建操作、累积有效辐射剂量、主要不良心脏事件（定义为非致命性心肌梗死和心源性死亡的复合终点）和医疗费用进行随访。cTCA组和stress-CMR组的平均随访时间相似（773.6±345天对752.8±291天；P = 0.21）。与stress-CMR相比，cTCA与更高的后续无创检查率（28%对17%；P = 0.0009）、侵入性冠状动脉造影率（31%对20%；P = 0.0009）和血运重建操作率（24%对16%；P = 0.007）相关。stress-CMR策略与辐射暴露和累积成本的显著降低相关（分别降低59%和24%；P < 0.001）。最后，接受stress-CMR检查的患者主要不良心脏事件发生率较低（5%对10%；P < 0.010），成本效益比也较低（119.98±250.92对218.12±298.45欧元/年；P < 0.001）。
与cTCA相比，stress-CMR在有血运重建史的有症状患者中更具成本效益。
