Department of Radiology, Mie University Graduate School of Medicine, Tsu, Mie, Japan.
Department of Advanced Diagnostic Imaging, Mie University Graduate School of Medicine, Tsu, Japan.
JACC Cardiovasc Imaging. 2020 Aug;13(8):1721-1734. doi: 10.1016/j.jcmg.2019.12.017. Epub 2020 Feb 12.
This study sought to evaluate the prognostic value of stress dynamic computed tomography (CT) perfusion (CTP) with CT delayed enhancement (CTDE) in patients with suspected or known coronary artery disease (CAD) and in subgroups of patients with stent, heavy calcification, or stenosis.
The prognostic value of stress dynamic CTP with CTDE is unknown.
Participants were 540 patients with suspected or known CAD. Major adverse cardiac event(s) (MACE) consisted of cardiac death, nonfatal myocardial infarction, unstable angina, or hospitalization for congestive heart failure. Ischemic score was calculated by scoring the reduction of normalized myocardial blood flow in 16 segments excluding areas of myocardial scarring. Ischemic perfusion defect (IPD) was defined as Ischemic score ≥4. Scar score was also calculated by scoring the transmural extent of scarring in each segment on CTDE.
During a median follow-up of 2.9 years, 43 MACEs occurred. By adding IPD to obstructive CAD (≥50% stenosis) on coronary CT angiography, the concordance index for predicting MACEs increased from 0.73 to 0.82 in patients with suspected CAD (p = 0.028) and from 0.61 to 0.73 in patients with known CAD (p = 0.004). IPD and scar score of ≥4 were independent predictors when adjusted for each other in patients with suspected (adjusted hazard ratios: 7.5 [p < 0.001] and 3.0 [p = 0.034], respectively) or known CAD (adjusted hazard ratios: 4.4 [p = 0.001] and 3.2 [p = 0.024], respectively). Patients with IPD had a higher annualized event rate than those without IPD in subgroups of those with stent (11.5% vs. 2.6%; p < 0.001), heavy calcification (13.3% vs. 3.1%; p < 0.001), 50% to 69% stenosis (8.8% vs. 1.0%; p < 0.001), or ≥70% stenosis (12.4% vs. 3.6%; p < 0.001).
Stress dynamic CTP with CTDE had incremental prognostic value over CT angiography in each group with suspected or known CAD and was prognostically useful in subgroups of patients with stent, heavy calcification, or obstructive CAD. IPD and myocardial scarring may play complementary roles in prognostic stratification.
本研究旨在评估疑似或已知冠状动脉疾病（CAD）患者以及支架、重度钙化或狭窄亚组患者中应激动态 CT 灌注（CTP）联合 CT 延迟增强（CTDE）的预后价值。
应激动态 CTP 联合 CTDE 的预后价值尚不清楚。
参与者为 540 名疑似或已知 CAD 患者。主要不良心脏事件（MACE）包括心脏死亡、非致死性心肌梗死、不稳定型心绞痛或充血性心力衰竭住院。缺血评分通过对 16 个节段（不包括心肌瘢痕区域）的正常化心肌血流减少进行评分来计算。缺血性灌注缺损（IPD）定义为缺血评分≥4。瘢痕评分也通过对 CTDE 上每个节段的瘢痕透壁程度进行评分来计算。
在中位数为 2.9 年的随访期间，发生了 43 例 MACE。在疑似 CAD 患者中，将 IPD 与冠状动脉 CT 血管造影上的阻塞性 CAD（≥50%狭窄）相加，预测 MACE 的一致性指数从 0.73 增加到 0.82（p=0.028），在已知 CAD 患者中从 0.61 增加到 0.73（p=0.004）。在疑似 CAD 患者（调整后的危险比：7.5[ p<0.001]和 3.0[ p=0.034]）或已知 CAD 患者（调整后的危险比：4.4[ p=0.001]和 3.2[ p=0.024]）中，当彼此相互调整时，IPD 和瘢痕评分≥4 是独立的预测因素。在支架（11.5%比 2.6%；p<0.001）、重度钙化（13.3%比 3.1%；p<0.001）、50%至 69%狭窄（8.8%比 1.0%；p<0.001）或≥70%狭窄（12.4%比 3.6%；p<0.001）亚组中，有 IPD 的患者比没有 IPD 的患者具有更高的年化事件率。
应激动态 CTP 联合 CTDE 比 CT 血管造影在疑似或已知 CAD 的每个组中具有额外的预后价值，并且在支架、重度钙化或阻塞性 CAD 的患者亚组中具有预后价值。IPD 和心肌瘢痕可能在预后分层中发挥互补作用。
