Roifman Idan, Wijeysundera Harindra C, Austin Peter C, Rezai Mohammad R, Wright Graham A, Tu Jack V
Institute for Clinical Evaluative Sciences (ICES), University of Toronto, Ontario, Canada.
Schulich Heart Program and the Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, University of Toronto, Ontario, Canada.
J Am Heart Assoc. 2017 Jul 19;6(7):e005462. doi: 10.1161/JAHA.116.005462.
The optimal initial noninvasive diagnostic testing strategy for stable coronary artery disease (CAD) is unknown. Although American guidelines recommend an exercise stress test as the first-line test, European guidelines suggest that stress imaging (myocardial perfusion imaging or stress echocardiography) or coronary computed tomography angiography may be preferable. Understanding the relationship between the initial strategy and downstream yield of obstructive CAD and major adverse cardiac events may provide insight as to the optimal strategy.
We conducted a population-based retrospective cohort study of adults in Ontario, Canada, using health administrative and clinical data. The relationship between the initial testing strategy and obstructive CAD on invasive angiography was examined. Patients were then followed from their angiogram onward to determine whether they developed a composite end point of major adverse cardiac events. After adjusting for covariates, patients with initial myocardial perfusion imaging (odds ratio: 0.92; 95% confidence interval, 0.85, 1.00), coronary computed tomography angiography (odds ratio: 1.51; 95% confidence interval, 0.91, 2.49), or stress echo (odds ratio: 0.95; 95% confidence interval, 0.84, 1.08) did not a have significantly different yield of obstructive CAD compared with those with an initial exercise stress test. Furthermore, there was no significant difference in downstream major adverse cardiac events after invasive angiography among the 4 initial testing strategies after adjusting for clinically relevant covariates.
Our study found no evidence to suggest significant differences in either yield of obstructive CAD or downstream major adverse cardiac events in patients undergoing an initial noninvasive testing strategy with stress or anatomical imaging compared with those undergoing an initial exercise stress test.
稳定型冠状动脉疾病（CAD）的最佳初始无创诊断测试策略尚不清楚。尽管美国指南推荐运动负荷试验作为一线测试，但欧洲指南表明，负荷成像（心肌灌注成像或负荷超声心动图）或冠状动脉计算机断层扫描血管造影可能更可取。了解初始策略与阻塞性CAD的下游检出率和主要不良心脏事件之间的关系，可能有助于洞察最佳策略。
我们利用卫生行政和临床数据，对加拿大安大略省的成年人进行了一项基于人群的回顾性队列研究。研究了初始测试策略与侵入性血管造影术中阻塞性CAD之间的关系。然后从血管造影开始对患者进行随访，以确定他们是否发生了主要不良心脏事件的复合终点。在对协变量进行调整后，与初始运动负荷试验的患者相比，初始进行心肌灌注成像（比值比：0.92；95%置信区间，0.85，1.00）、冠状动脉计算机断层扫描血管造影（比值比：1.51；95%置信区间，0.91，2.49）或负荷超声心动图（比值比：0.95；95%置信区间，0.84，1.08）的患者，阻塞性CAD的检出率没有显著差异。此外，在对临床相关协变量进行调整后，4种初始测试策略在侵入性血管造影术后的下游主要不良心脏事件方面没有显著差异。
我们的研究发现，与初始进行运动负荷试验的患者相比，初始采用负荷或解剖成像的无创测试策略的患者，在阻塞性CAD的检出率或下游主要不良心脏事件方面，均无证据表明存在显著差异。
