瑞士常规临床实践中在进行有创冠状动脉造影之前的无创评估 - 是否符合指南？
Non-invasive assessment prior to invasive coronary angiography in routine clinical practice in Switzerland - Is it according to the guidelines?
机构信息
Cardiology Department, Kantonsspital St. Gallen, Switzerland.
出版信息
PLoS One. 2019 Sep 6;14(9):e0222137. doi: 10.1371/journal.pone.0222137. eCollection 2019.
BACKGROUND
Non-invasive testing is recommended as a basis to decide about the indication for invasive coronary angiography (ICA) in patients with suspected stenotic coronary artery disease (CAD). However, a recent study based on insurance claims data reported that one third of patients undergoing ICA in Switzerland did not have non-invasive testing beforehand. We aimed to re-evaluate the practice of testing prior to ICA in Switzerland by manual review of patient histories.
METHODS
Retrospective analysis of all 816 consecutive patients (age 67±9 years, 70% males) undergoing elective ICA solely for the evaluation of stenotic CAD during the year 2015 in a single center in Eastern Switzerland. The proportion of patients undergoing a non-invasive test was assessed, and predictors of the lack of such a test were determined.
RESULTS
764/816 (94%) patients had a non-invasive test prior to ICA. The majority of patients (728/816; 89%) had an exercise stress test, one fifth (160/816; 20%) underwent a test other than an exercise stress test (6% scintigraphy, 4% stress echocardiography, 6% stress magnetic resonance imaging, 4% computed tomography coronary angiography), and 122/816 (15%) patients had two tests. The use of antianginal drugs other than beta-blockers [odds ratio 1.92 (95% confidence interval 1.01-3.66); p = 0.047] and a lower left ventricular ejection fraction [odds ratio 0.97 (95% confidence interval 0.94-0.99) per one % point increase; p = 0.005] were independent predictors of the lack of a non-invasive test. ICA revealed stenotic CAD in 72% of patients, and 54% of patients underwent revascularization. Patients with and without non-invasive tests did not differ with respect to ICA findings and management.
CONCLUSIONS
The present analysis suggests that patients are appropriately selected for ICA based on clinical judgement and non-invasive testing in Switzerland. There is no evidence for an overuse of ICA.
背景
非侵入性检查被推荐作为决定是否对疑似狭窄性冠状动脉疾病（CAD）患者进行有创冠状动脉造影（ICA）的依据。然而，最近一项基于保险索赔数据的研究报告称，瑞士三分之一接受 ICA 的患者在此之前没有进行非侵入性检查。我们旨在通过手动审查患者病史来重新评估瑞士 ICA 之前的检查实践。
方法
对 2015 年在瑞士东部一家单一中心接受选择性 ICA 仅用于评估狭窄性 CAD 的 816 例连续患者（年龄 67±9 岁，70%为男性）进行回顾性分析。评估接受非侵入性检查的患者比例，并确定缺乏此类检查的预测因素。
结果
764/816（94%）例患者在 ICA 前进行了非侵入性检查。大多数患者（728/816；89%）接受了运动应激试验，五分之一（160/816；20%）接受了运动应激试验以外的检查（6%闪烁扫描、4%应激超声心动图、6%应激磁共振成像、4%计算机断层冠状动脉造影），122/816（15%）例患者接受了两项检查。除β受体阻滞剂外使用抗心绞痛药物[比值比 1.92（95%置信区间 1.01-3.66）；p = 0.047]和左心室射血分数较低[比值比 0.97（95%置信区间 0.94-0.99）每增加 1%；p = 0.005]是缺乏非侵入性检查的独立预测因素。ICA 显示 72%的患者存在狭窄性 CAD，54%的患者接受了血运重建。接受和未接受非侵入性检查的患者在 ICA 结果和管理方面没有差异。
结论
本分析表明，瑞士根据临床判断和非侵入性检查对 ICA 进行了适当选择。没有证据表明 ICA 过度使用。
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