Division of Cardiology University Hospital of Lausanne (CHUV), Lausanne, Switzerland; Cardiac MR Center, University Hospital of Lausanne (CHUV), Lausanne, Switzerland.
Division of Cardiology University Hospital of Lausanne (CHUV), Lausanne, Switzerland.
JACC Cardiovasc Imaging. 2017 May;10(5):526-537. doi: 10.1016/j.jcmg.2017.02.006. Epub 2017 Apr 12.
This study sought to determine the ischemia threshold and additional prognostic factors that identify patients for safe deferral from revascularizations in a large cohort of all-comer patients with known or suspected coronary artery disease (CAD).
Stress-perfusion cardiac magnetic resonance (CMR) is increasingly used in daily practice for ischemia detection. However, there is insufficient evidence about the ischemia burden that identifies patients who benefit from revascularization versus those with a good prognosis who receive drugs only.
All patients with known or suspected CAD referred to stress-perfusion CMR for myocardial ischemia assessment were prospectively enrolled. The CMR examination included standard functional adenosine stress first-pass perfusion (gadobutrol 0.1 mmol/kg Gadovist, Bayer AG, Zurich, Switzerland) and late gadolinium enhancement (LGE) acquisitions. Presence of ischemia and ischemia burden (number of ischemic segments on a 16-segment model), and of scar and scar burden (number and transmurality of scar segments in a 17-segment model) were assessed. The primary endpoint was a composite of cardiac death, nonfatal myocardial infarction (MI), and late coronary revascularization (>90 days post-CMR); the secondary endpoint was a composite of cardiac death and nonfatal MI.
During a follow-up of 2.5 ± 1.0 years, 86 and 32 of 1,024 patients (1,103 screened patients) experienced the primary and secondary endpoints, respectively. On Kaplan-Meier curves for the primary and secondary endpoints, patients without ischemia had excellent outcomes that did not differ from patients with <1.5 ischemic segments. In multivariate Cox regression analyses of the entire population and of the subgroups, ischemia burden (threshold: ≥1.5 ischemic segments) was consistently the strongest predictor of the primary and secondary endpoints with hazard ratios (HRs) of 7.42 to 8.72 (p < 0.001), whereas age (≥67 years), left ventricular ejection fraction (≤40%), and scar burden (LGE score ≥0.03) contributed significantly, but to a lesser extent, in all models with HRs of 2.01 to 3.48, 1.75 to 1.96, and 1.66 to 1.76, respectively.
In a large all-comer patient cohort with known and suspected CAD, an ischemia burden of ≥1.5 ischemic segments on stress-perfusion CMR was the strongest predictor of the primary and secondary endpoints. Patients with zero or 1 ischemic segment can be safely deferred from revascularizations.
本研究旨在确定缺血阈值和其他预后因素，以便在患有已知或疑似冠状动脉疾病（CAD）的大患者队列中，确定可安全推迟血运重建的患者。
应激灌注心脏磁共振（CMR）越来越多地用于缺血检测的日常实践中。然而，关于确定哪些患者受益于血运重建，哪些患者预后良好只需药物治疗的缺血负担证据不足。
所有患有已知或疑似 CAD 并因心肌缺血评估而行应激灌注 CMR 的患者均前瞻性入组。CMR 检查包括标准功能腺苷首过灌注（0.1mmol/kg 钆布醇，拜耳公司，苏黎世，瑞士）和晚期钆增强（LGE）采集。评估缺血的存在和缺血负担（16 节段模型上的缺血节段数），以及瘢痕和瘢痕负担（17 节段模型上的瘢痕节段数和透壁性）。主要终点是心脏死亡、非致死性心肌梗死（MI）和晚期冠状动脉血运重建（CMR 后>90 天）的复合终点；次要终点是心脏死亡和非致死性 MI 的复合终点。
在 2.5±1.0 年的随访期间，1024 例患者中有 86 例（1103 例筛查患者）和 32 例经历了主要和次要终点。在主要和次要终点的 Kaplan-Meier 曲线中，无缺血的患者预后良好，与<1.5 个缺血节段的患者无差异。在整个队列和亚组的多变量 Cox 回归分析中，缺血负担（阈值：≥1.5 个缺血节段）始终是主要和次要终点的最强预测因素，风险比（HR）为 7.42 至 8.72（p<0.001），而年龄（≥67 岁）、左心室射血分数（≤40%）和瘢痕负担（LGE 评分≥0.03）在所有模型中也有显著但程度较小的贡献，HR 分别为 2.01 至 3.48、1.75 至 1.96 和 1.66 至 1.76。
在患有已知和疑似 CAD 的大患者队列中，应激灌注 CMR 上≥1.5 个缺血节段的缺血负担是主要和次要终点的最强预测因素。零或 1 个缺血节段的患者可安全推迟血运重建。
