Department of Cardiology, Erasmus University Medical Center, Rotterdam, the Netherlands; Department of Radiology, Erasmus University Medical Center, Rotterdam, the Netherlands.
Department of Cardiology, Erasmus University Medical Center, Rotterdam, the Netherlands; Department of Radiology, Erasmus University Medical Center, Rotterdam, the Netherlands.
JACC Cardiovasc Imaging. 2018 Nov;11(11):1625-1636. doi: 10.1016/j.jcmg.2017.10.010. Epub 2017 Dec 13.
This study sought to assess the effectiveness, efficiency, and safety of a tiered, comprehensive cardiac computed tomography (CT) protocol in comparison with functional testing.
Although CT angiography accurately rules out coronary artery disease (CAD), incorporation of CT myocardial perfusion imaging as part of a tiered diagnostic approach could improve the clinical value and efficiency of cardiac CT in the diagnostic work-up of patients with angina pectoris.
Between July 2013 and November 2015, 268 patients (mean age 58 years; 49% female) with stable angina (mean pre-test probability 54%) were prospectively randomized between cardiac CT and standard guideline-directed functional testing (95% exercise electrocardiography). The tiered cardiac CT protocol included a calcium scan, followed by CT angiography if calcium was detected. Patients with ≥50% stenosis on CT angiography underwent CT myocardial perfusion imaging.
By 6 months, the primary endpoint, the rate of invasive coronary angiograms without a European Society of Cardiology class I indication for revascularization, was lower in the CT group than in the functional testing group (2 of 130 [1.5%] vs. 10 of 138 [7.2%]; p = 0.035), whereas the proportion of invasive angiograms with a revascularization indication was higher (88% vs. 50%; p = 0.017). The median duration until the final diagnosis was 0 (0 of 0) days in the CT group and 0 (0 of 17) in the functional testing group (p < 0.001). Overall, 13% of patients randomized to CT required further testing, compared with 37% in the functional testing group (p < 0.001). The adverse event rate was similar (3% vs. 3%; p = 1.000), although the median cumulative radiation dose was higher for the CT group (3.1 mSv [interquartile range: 1.6 to 7.8] vs. 0 mSv [interquartile range: 0.0 to 7.1]; p < 0.001).
In patients with suspected stable CAD, a tiered cardiac CT protocol with dynamic perfusion imaging offers a fast and efficient alternative to functional testing. (Comprehensive Cardiac CT Versus Exercise Testing in Suspected Coronary Artery Disease 2 [CRESCENT2]; NCT02291484).
本研究旨在评估分层综合心脏 CT（CT）方案与功能测试相比的有效性、效率和安全性。
虽然 CT 血管造影术可准确排除冠状动脉疾病（CAD），但将 CT 心肌灌注成像纳入分层诊断方法可能会提高心脏 CT 在心绞痛患者诊断中的临床价值和效率。
2013 年 7 月至 2015 年 11 月，前瞻性随机将 268 例（平均年龄 58 岁；49%为女性）稳定型心绞痛患者（平均术前概率 54%）分为心脏 CT 组和标准指南导向的功能测试（95%运动心电图）组。分层心脏 CT 方案包括钙扫描，如果检测到钙，则进行 CT 血管造影。CT 血管造影显示≥50%狭窄的患者行 CT 心肌灌注成像。
6 个月时，主要终点为无欧洲心脏病学会（ESC）血管重建 I 类适应证的侵入性冠状动脉造影的发生率，CT 组低于功能测试组（2/130[1.5%]比 10/138[7.2%]；p=0.035），而有血管重建适应证的侵入性血管造影比例更高（88%比 50%；p=0.017）。CT 组的中位最终诊断时间为 0（0/0）天，功能测试组为 0（0/17）天（p<0.001）。总体而言，与功能测试组的 37%相比，随机分到 CT 组的患者需要进一步检查的比例为 13%（p<0.001）。不良事件发生率相似（3%比 3%；p=1.000），但 CT 组的中位累积辐射剂量更高（3.1mSv[四分位距：1.6 至 7.8]比 0mSv[四分位距：0.0 至 7.1]；p<0.001）。
在疑似稳定型 CAD 患者中，动态灌注成像的分层心脏 CT 方案是功能测试的快速、有效的替代方法。（疑似冠状动脉疾病的综合心脏 CT 与运动试验 2[CRESCENT2]；NCT02291484）。
