冠状动脉钙化对急性胸痛患者临床管理的影响
Impact of Coronary Calcification on Clinical Management in Patients With Acute Chest Pain.
作者信息
Bittner Daniel O, Mayrhofer Thomas, Bamberg Fabian, Hallett Travis R, Janjua Sumbal, Addison Daniel, Nagurney John T, Udelson James E, Lu Michael T, Truong Quynh A, Woodard Pamela K, Hollander Judd E, Miller Chadwick, Chang Anna Marie, Singh Harjit, Litt Harold, Hoffmann Udo, Ferencik Maros
机构信息
From the Cardiac MR PET CT Program (D.O.B., T.M., F.B., T.R.H., S.J., D.A., M.T.L., U.H., M.F.), Department of Radiology (D.O.B., T.M., T.R.H., S.J., D.A., M.T.L., U.H., M.F.), and Department of Emergency Medicine (J.T.N.), Massachusetts General Hospital, Harvard Medical School, Boston; Department of Cardiology, University Hospital Erlangen, Friedrich-Alexander University Erlangen-Nürnberg (FAU), Germany (D.O.B.); School of Business Studies, Stralsund University of Applied Sciences, Germany (T.M.); Department of Diagnostic and Interventional Radiology, University of Tuebingen, Germany (F.B.); Division of Cardiology and the CardioVascular Center, Tufts Medical Center, Boston, MA (J.E.U.); Department of Radiology, Weill Cornell Medicine, New York City (Q.A.T.); Mallinckrodt Institute of Radiology, Washington University School of Medicine, St Louis, MO (P.K.W.); Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, PA (J.E.H., A.M.C.); Department of Emergency Medicine, Wake Forest School of Medicine, Winston-Salem, NC (C.M.); Penn State Heart and Vascular Institute, Hershey, PA (H.S.); Perelman School of Medicine of the University of Pennsylvania, Philadelphia (H.L.); and Knight Cardiovascular Institute, Oregon Health and Science University, Portland (M.F.).
出版信息
Circ Cardiovasc Imaging. 2017 May;10(5). doi: 10.1161/CIRCIMAGING.116.005893.
BACKGROUND
Coronary artery calcification (CAC) may impair diagnostic assessment of coronary computed tomography angiography (CTA). We determined whether CAC affects efficiency of coronary CTA in patients with suspected acute coronary syndrome (ACS).
METHODS AND RESULTS
This is a pooled analysis of ACRIN-PA (American College of Radiology Imaging Network-Pennsylvania) 4005 and the ROMICAT-II trial (Rule Out Myocardial Infarction/Ischemia Using Computer Assisted Tomography) comparing an initial coronary CTA strategy to standard of care in acute chest pain patients. In the CTA arms, we investigated appropriateness of downstream testing, cost, and diagnostic yield to identify patients with obstructive coronary artery disease on subsequent invasive coronary angiography across CAC score strata (Agatston score: 0, >0-10, >10-100, >100-400, >400). Out of 1234 patients (mean age 51±8.8 years), 80 (6.5%) had obstructive coronary artery disease (≥70% stenosis) and 68 (5.5%) had ACS. Prevalence of obstructive coronary artery disease (1%-64%), ACS (1%-44%), downstream testing (4%-72%), and total (2337-8484 US$) and diagnostic cost (2310-6678 US$) increased across CAC strata (<0.001). As the increase in testing and cost were lower than the increase of ACS rate in patients with CAC>400, cost to diagnose one ACS was lowest in this group (19 283 US$ versus 464 399 US$) as compared with patients without CAC. The diagnostic yield of invasive coronary angiography was highest in patients with CAC>400 (87% versus 38%).
CONCLUSIONS
Downstream testing, total, and diagnostic cost increased with increasing CAC, but were found to be appropriate because obstructive coronary artery disease and ACS were more prevalent in patients with high CAC. In patients with acute chest pain undergoing coronary CTA, cost-efficient testing and excellent diagnostic yield can be achieved even with high CAC burden.
CLINICAL TRIAL REGISTRATION
URL: http://www.clinicaltrials.gov. Unique identifiers: NCT01084239 and NCT00933400.
背景
冠状动脉钙化（CAC）可能会影响冠状动脉计算机断层扫描血管造影（CTA）的诊断评估。我们确定了CAC是否会影响疑似急性冠状动脉综合征（ACS）患者的冠状动脉CTA效率。
方法与结果
这是一项对ACRIN-PA（美国放射学会影像网络-宾夕法尼亚）4005研究和ROMICAT-II试验（使用计算机辅助断层扫描排除心肌梗死/缺血）的汇总分析，比较了急性胸痛患者的初始冠状动脉CTA策略与标准治疗。在CTA组中，我们调查了下游检查的适宜性、成本和诊断率，以确定在不同CAC评分分层（阿加斯顿评分：0、>0-10、>10-100、>100-400、>400）的后续有创冠状动脉造影中患有阻塞性冠状动脉疾病的患者。在1234例患者（平均年龄51±8.8岁）中，80例（6.5%）患有阻塞性冠状动脉疾病（狭窄≥70%），68例（5.5%）患有ACS。阻塞性冠状动脉疾病（1%-64%）、ACS（1%-44%）、下游检查（4%-72%）以及总费用（2337-8484美元）和诊断费用（2310-6678美元）在不同CAC分层中均有所增加（<0.001）。由于CAC>400的患者中检查和费用的增加低于ACS发生率的增加，该组诊断一例ACS的成本最低（19283美元对464399美元），与无CAC的患者相比。在CAC>400的患者中，有创冠状动脉造影的诊断率最高（87%对38%）。
结论
随着CAC增加，下游检查、总费用和诊断成本增加，但被认为是适宜的，因为阻塞性冠状动脉疾病和ACS在高CAC患者中更为普遍。在接受冠状动脉CTA的急性胸痛患者中，即使CAC负担较高，也可实现成本效益高的检查和出色的诊断率。
临床试验注册
网址：http://www.clinicaltrials.gov。唯一标识符：NCT01084239和NCT00933400。
Zotero 插件