Department of Medicine, Medical University of South Carolina, Charleston, SC, USA.
Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC, USA.
J Cardiovasc Comput Tomogr. 2019 Jul-Aug;13(4):211-218. doi: 10.1016/j.jcct.2019.03.010. Epub 2019 Mar 27.
Obesity is a risk factor for coronary artery disease (CAD), but adiposity may mimic symptoms of CAD and reduce the accuracy of diagnostic testing.
Patients from the PROMISE trial (n = 8889) were classified according to body mass index (BMI). We assessed relationships between BMI, physician's preference of functional test, test positivity, and results of invasive coronary angiography (Cath) using logistic regression models.
Nearly half (48%) of the patients had BMI ≥ 30 kg/m, and 20% had BMI ≥ 35. Providers were more likely to prefer nuclear myocardial perfusion imaging (MPI) over other functional tests as BMI increased. The rate of test positivity with coronary computed tomographic angiography (CTA) was not different (10% vs. 12%) in patients with BMI ≥35 vs. < 35. The same was true for stress echocardiogram and stress electrocardiogram (positivity 8-13%, P > 0.8 for both). In contrast, MPI was significantly more likely to be positive in those with BMI ≥35 vs. <35 (18% vs. 13%; P = 0.001). The likelihood of obstructive CAD at Cath did not differ with BMI ≥35 vs. <35 in patients having CTA (52% vs. 59%, P = 0.22), but among MPI patients, Cath positivity was only 29% with BMI ≥35 vs. 48% with BMI <35 (P = 0.005). Radiation exposure increased with higher BMI in both MPI and CTA groups.
Increasing levels of obesity adversely affect the diagnostic yield of MPI more than CTA. The degree of obesity should be considered when choosing evaluation strategies for patients with chest pain.
PROMISE ClinicalTrials.gov number, NCT01174550.
肥胖是冠心病（CAD）的一个危险因素，但脂肪过多可能会模仿 CAD 的症状，降低诊断测试的准确性。
根据体重指数（BMI）将 PROMISE 试验（n=8889）的患者进行分类。我们使用逻辑回归模型评估 BMI 与医生对功能测试的偏好、测试阳性率以及侵入性冠状动脉造影（Cath）结果之间的关系。
近一半（48%）的患者 BMI≥30kg/m，20%的患者 BMI≥35kg/m。随着 BMI 的增加，医生更倾向于选择核心肌灌注成像（MPI）而不是其他功能测试。在 BMI≥35kg/m 和<35kg/m 的患者中，冠状动脉计算机断层扫描血管造影（CTA）的阳性率无差异（10% vs. 12%）。负荷超声心动图和运动心电图也是如此（阳性率 8-13%，两者均 P>0.8）。相反，在 BMI≥35kg/m 和<35kg/m 的患者中，MPI 阳性的可能性明显更高（18% vs. 13%；P=0.001）。在接受 CTA 的患者中，Cath 阳性与 BMI≥35kg/m 和<35kg/m 之间的差异无统计学意义（52% vs. 59%，P=0.22），但在 MPI 患者中，BMI≥35kg/m 的 Cath 阳性率仅为 29%，而 BMI<35kg/m 的 Cath 阳性率为 48%（P=0.005）。MPI 和 CTA 组的辐射暴露均随 BMI 的增加而增加。
肥胖程度的增加对 MPI 的诊断收益产生不利影响，比 CTA 更明显。在为胸痛患者选择评估策略时，应考虑肥胖程度。
PROMISE 临床试验注册，NCT01174550。
