Nagel E, Carerj M L, Arendt C T, Puntmann V O
Institute of Experimental and Translational Cardiac Imaging, DZHK Centre for Cardiovascular Imaging, University Hospital Frankfurt, Theodor-Stern-Kai 7, 60590, Frankfurt am Main, Germany.
Section of Radiological Sciences, Department of Biomedical Sciences and Morphological and Functional Imaging, Policlinico G. Martino, University Hospital Messina, Messina, Italy.
Herz. 2020 Aug;45(5):446-452. doi: 10.1007/s00059-020-04936-w.
This review surveys the findings of the International Study of Comparative Health Effectiveness with Medical and Invasive Approaches (ISCHEMIA) trial and puts them into a clinical perspective regarding its effect of the role of cardiac magnetic resonance imaging (CMR) as a well-validated gatekeeper for invasive angiography and myocardial revascularization. Noninvasive stress testing of patients with intermediate-to-high pretest likelihood for obstructive coronary artery disease (CAD) using perfusion CMR provides excellent diagnostic accuracy in detecting ischemic myocardium, and additional information from tissue characterization can guide the management of patients with stable angina toward a more individualized therapy as other non-coronary underlying causes of chest pain can be detected. Since ISCHEMIA failed to show that an invasive strategy using percutaneous coronary intervention or coronary artery bypass grafting was associated with an improved prognosis compared with initial conservative medical therapy among stable patients with moderate-to-severe ischemia, CMR as a multifaceted diagnostic imaging approach to explain patients' symptoms should be preferred over anatomical and stress testing alone. Nevertheless, the exclusion of left main coronary artery stenosis either by coronary CT or MR angiography may be required. In conclusion, the results of the ISCHEMIA trial are in good accordance with those of the MR-INFORM trial recently published in the New England Journal of Medicine, as the noninvasive management of a large proportion of patients with CAD was shown to be noninferior to current invasive strategies. Recent outcome data from trials may therefore have an impact on future guidelines to further reduce the execution of unnecessary left heart catheterizations.
本综述调查了国际医学与侵入性方法比较健康效果研究（ISCHEMIA）试验的结果，并从临床角度探讨了心脏磁共振成像（CMR）作为侵入性血管造影和心肌血运重建的有效把关手段所起的作用。对于冠状动脉疾病（CAD）预测试验可能性为中到高的患者，使用灌注CMR进行无创负荷试验在检测缺血心肌方面具有出色的诊断准确性，并且组织特征分析提供的额外信息可以指导稳定型心绞痛患者的治疗，使其更加个体化，因为可以检测出其他非冠状动脉性胸痛的潜在病因。由于ISCHEMIA未能表明，在中度至重度缺血的稳定患者中，与初始保守药物治疗相比，采用经皮冠状动脉介入治疗或冠状动脉旁路移植术的侵入性策略能改善预后，因此，作为一种能解释患者症状的多方面诊断成像方法，CMR应优于单纯的解剖学检查和负荷试验。尽管如此，可能仍需要通过冠状动脉CT或磁共振血管造影排除左主干冠状动脉狭窄。总之，ISCHEMIA试验的结果与最近发表在《新英格兰医学杂志》上的MR-INFORM试验的结果高度一致，因为大量CAD患者的无创管理被证明不劣于当前的侵入性策略。因此，近期试验的结果数据可能会对未来的指南产生影响，以进一步减少不必要的左心导管检查的实施。
