Greulich Simon, Backes Maik, Steubing Hannah, Seitz Andreas, Chatzitofi Maria, Kaesemann Philipp, Andre Florian, Buss Sebastian J, Katus Hugo A, Mahrholdt Heiko
Department of Cardiology and Cardiovascular Diseases, University of Tübingen, Tübingen.
Division of Cardiology.
Coron Artery Dis. 2019 May;30(3):222-231. doi: 10.1097/MCA.0000000000000705.
The diagnostic performance of adenosine stress cardiovascular magnetic resonance (CMR) for the detection of significant stenosis in infarct-related arteries is widely unknown. Two different types of perfusion defects can be observed: (a) larger than or (b) equal size as scar.We hypothesized that: (a) defect>scar predicts significant coronary stenosis, and (b) defect=scar predicts an unobstructed infarct-related artery, and (c) angina symptoms might be of additional value in stratification.
Patients with previous myocardial infarction referred for work-up of myocardial ischemia undergoing adenosine stress CMR were included if they had coronary angiography within 4 weeks of CMR.
Two hundred patients with a mean age of 66±11 years, ischemic scars (subendocardial/transmural), and a mean left ventricular ejection fraction of 53% were included. In patients with defect>scar, the positive predictive value was excellent (88%) and typical angina was reported only in the stenosis group (P=0.002). However, patients with defect=scar (with 50% showing subendocardial scar) had a prevalence of 37% for stenosis, yielding a low negative predictive value of 63%. In this group, symptoms of typical angina were independent of stenosis (P=1.0).
A perfusion defect larger than scar is highly predictive for significant stenosis in infarct-related arteries. However, more than a third of the patients with perfusion defect of equal size as scar also showed significant coronary stenosis. As half of these patients showed still viable (subendocardial) scars, there is a high-risk of reinfarction. The addition of angina symptoms seems to increase diagnostic accuracy only in patients with perfusion defects larger than scar.
腺苷负荷心血管磁共振成像（CMR）检测梗死相关动脉严重狭窄的诊断性能尚不明确。可观察到两种不同类型的灌注缺损：（a）大于瘢痕或（b）与瘢痕大小相等。我们假设：（a）缺损>瘢痕提示严重冠状动脉狭窄，（b）缺损=瘢痕提示梗死相关动脉通畅，（c）心绞痛症状在分层中可能具有额外价值。
纳入因心肌缺血接受腺苷负荷CMR检查的既往心肌梗死患者，条件是在CMR检查后4周内进行冠状动脉造影。
纳入200例患者，平均年龄66±11岁，存在缺血性瘢痕（心内膜下/透壁），平均左心室射血分数为53%。在缺损>瘢痕的患者中，阳性预测值极佳（88%），且仅狭窄组报告有典型心绞痛（P=0.002）。然而，缺损=瘢痕的患者（其中50%为心内膜下瘢痕）狭窄患病率为37%，阴性预测值低至63%。在该组中，典型心绞痛症状与狭窄无关（P=1.0）。
灌注缺损大于瘢痕对梗死相关动脉严重狭窄具有高度预测性。然而，超过三分之一的灌注缺损与瘢痕大小相等的患者也存在严重冠状动脉狭窄。由于这些患者中有一半仍存在存活（心内膜下）瘢痕，再次梗死风险很高。仅在灌注缺损大于瘢痕的患者中增加心绞痛症状似乎可提高诊断准确性。
