Orde Sam, Slama Michel, Pathan Faraz, Huang Stephen, Mclean Anthony
Intensive Care Unit, Nepean Hospital, Sydney, 2750, Australia.
Intensive Care Unit, Nepean Hospital, Kingswood, Sydney, NSW, 2749, Australia.
Crit Care. 2019 Jul 17;23(1):257. doi: 10.1186/s13054-019-2519-1.
Diagnosis of significant coronary artery disease (CAD) and acute coronary artery occlusion in ICU can be difficult, and an inappropriate intervention is potentially harmful. Myocardial contrast perfusion echo (MCPE) examines ultrasound contrast intensity replenishment curves in individual myocardial segments measuring peak contrast intensity and slope of return as an index of myocardial blood flow (units = intensity of ultrasound per second [dB/s]). MCPE could possibly serve as a triage tool to invasive angiography by estimating blood flow in the myocardium. We sought to assess feasibility in the critically ill and if MCPE could add incremental value to the clinical acumen in predicting significant CAD.
This is a single-centre, prospective, observational study. Inclusion criteria were as follows: adult ICU patients with troponin I > 50 ng/L and cardiology referral being made for consideration of inpatient angiography. Exclusion criteria were as follows: poor echo windows (2 patients), known ischaemic heart disease, and contrast contraindications. Seven cardiologists and 6 intensivists blinded to outcome assessed medical history, ECG, troponin, and 2D echo images to estimate likelihood of significant CAD needing intervention (clinical acumen). Clinical acumen, quantitative MCPE, and subjective (visual) MCPE were assessed to predict significant CAD.
Forty patients underwent MCPE analysis, 6 (15%) had significant CAD, and median 11 of 16 segments (IQR 8-13) could be imaged (68.8% [IQR 50-81]). No adverse events occurred. A significant difference was found in overall MCPE blood flow estimation between those diagnosed with significant CAD and those without (3.3 vs 2.4 dB/s, p = 0.050). A MCPE value of 2.8 dB/s had 67% sensitivity and 88% specificity in detecting significant CAD. Clinical acumen showed no association in prediction of CAD (OR 0.6, p = 0.09); however, if quantitative or visual MCPE analysis was included, a significant association occurred (OR 17.1, p = 0.01; OR 23.0, p = 0.01 respectively).
MCPE is feasible in the critically ill and shows better association with predicting significant CAD vs clinical acumen alone. MCPE adds incremental value to initial assessment of the presence of significant CAD which may help guide those who require urgent angiography.
在重症监护病房（ICU）中，诊断严重冠状动脉疾病（CAD）和急性冠状动脉闭塞可能具有挑战性，不恰当的干预可能有害。心肌对比灌注超声心动图（MCPE）通过检测各个心肌节段的超声对比剂强度补充曲线，测量对比剂峰值强度和恢复斜率作为心肌血流指标（单位 = 每秒超声强度 [dB/s]）。MCPE 有可能作为一种分诊工具，通过估计心肌血流来指导侵入性血管造影。我们旨在评估其在危重症患者中的可行性，以及 MCPE 是否能为预测严重 CAD 的临床敏锐度增加额外价值。
这是一项单中心、前瞻性、观察性研究。纳入标准如下：肌钙蛋白 I > 50 ng/L 的成年 ICU 患者，且因考虑住院血管造影而被转诊至心内科。排除标准如下：超声心动图窗不佳（2 例患者）、已知缺血性心脏病和对比剂禁忌证。7 名心脏病专家和 6 名重症医学专家在不知晓结果的情况下评估病史、心电图、肌钙蛋白和二维超声心动图图像，以估计需要干预的严重 CAD 的可能性（临床敏锐度）。评估临床敏锐度、定量 MCPE 和主观（视觉）MCPE 以预测严重 CAD。
40 例患者接受了 MCPE 分析，6 例（15%）患有严重 CAD，16 个节段中中位数 11 个节段（四分位间距 8 - 13）可成像（68.8% [四分位间距 50 - 81]）。未发生不良事件。在诊断为严重 CAD 的患者和未患严重 CAD 的患者之间，整体 MCPE 血流估计存在显著差异（3.3 与 2.4 dB/s，p = 0.050）。MCPE 值为 2.8 dB/s 在检测严重 CAD 时具有 67% 的灵敏度和 88% 的特异度。临床敏锐度在预测 CAD 方面无相关性（比值比 0.6，p = 0.09）；然而，如果纳入定量或视觉 MCPE 分析，则存在显著相关性（分别为比值比 17.1，p = 0.01；比值比 23.0，p = 0.01）。
MCPE 在危重症患者中是可行的，并且与单独的临床敏锐度相比，在预测严重 CAD 方面显示出更好的相关性。MCPE 为严重 CAD 存在与否的初始评估增加了额外价值，这可能有助于指导那些需要紧急血管造影的患者。
