Gul Maryam, Sheikh Mubashir, Chaudhry Abbas, Gerges Luke, Al Halabi Hadi, Feldman Eric, Chaudhry Ammar
Precision Rheumatology, Anaheim, CA, USA.
Department of Diagnostic and Interventional Radiology, City of Hope National Medical Center, Duarte, CA, USA.
J Thorac Dis. 2020 Sep;12(9):5067-5077. doi: 10.21037/jtd-2019-pitd-12.
Clinical workup for chest pain varies among institutions. Acute coronary syndrome (ACS) is the primary diagnosis to rule out in the differential diagnosis, due to its associated mortality and morbidity. Although studies have demonstrated efficacy of coronary computed tomographic angiography (CCTA) in diagnosis obstructive coronary artery disease (CAD), there is limited evidence in the clinical value of performing cardiac nuclear stress perfusion imaging [myocardial perfusion imaging (MPI)] exam in patients with chest pain after undergoing CCTA. We aim to evaluate clinical value of follow-up nuclear cardiac MPI in patients with chest pain who have undergone recent CCTA.
A total of 1,000 patients were evaluated in this IRB approved retrospective study who presented with symptoms of ACS. Patients who had elevated troponin or abnormal electrocardiogram (ECG) findings at initial presentation or prior to cardiac nuclear MPI were excluded from the study. All patients who underwent 64- or 320-detector row ECG-gated CCTA as well as a follow-up nuclear MPI. Patients who had diagnostics studies limited by artifact [e.g., suboptimal intravenous (IV) contrast bolus in CCTA, motion artifact on CCTA or MPI, etc.] were excluded.
One hundred patients met the inclusion criteria. Patient demographics include average age 64.3 [32-89] years, 59 male, 41 females. Ninety-five/100 patients had at least one vessel with 50-70% coronary artery diameter stenosis measured on CCTA. There were no focal perfusion abnormalities identified on cardiac nuclear MPI in patients with less than 70% stenosis diagnosed on CCTA. Five percent of patients were identified with coronary arterial narrowing greater than 70% on CCTA and all 5 of these patients have evidence of abnormal cardiac nuclear stress test (perfusion abnormalities, chest pain, abnormal ECG).
In low-to-intermediate risk patients with chest pain and evidence of non-critical coronary artery stenosis (i.e., less than 70% stenosis) diagnosed on CCTA, a follow-up cardiac nuclear perfusion imaging is of limited value.
不同机构对胸痛的临床检查方法各异。急性冠状动脉综合征（ACS）因其相关的死亡率和发病率，是鉴别诊断中需要排除的主要疾病。尽管研究已证实冠状动脉计算机断层血管造影（CCTA）在诊断阻塞性冠状动脉疾病（CAD）方面的有效性，但对于接受CCTA检查后的胸痛患者进行心脏核素负荷灌注成像[心肌灌注成像（MPI）]检查的临床价值，证据有限。我们旨在评估近期接受CCTA检查的胸痛患者进行后续心脏核素MPI检查的临床价值。
在这项经机构审查委员会批准的回顾性研究中，共评估了1000例出现ACS症状的患者。在初始就诊时或进行心脏核素MPI检查之前肌钙蛋白升高或心电图（ECG）结果异常的患者被排除在研究之外。所有患者均接受了64排或320排心电图门控CCTA以及后续的心脏核素MPI检查。因伪影导致诊断研究受限的患者（例如，CCTA中静脉注射造影剂不理想、CCTA或MPI上的运动伪影等）被排除。
100例患者符合纳入标准。患者人口统计学特征包括平均年龄64.3[32 - 89]岁，男性59例，女性41例。95/100例患者在CCTA上测量发现至少有一支血管存在50% - 70%的冠状动脉直径狭窄。在CCTA诊断狭窄小于70%的患者中，心脏核素MPI未发现局灶性灌注异常。5%的患者在CCTA上被发现冠状动脉狭窄大于70%，所有这5例患者均有心脏核素负荷试验异常的证据（灌注异常、胸痛、心电图异常）。
对于CCTA诊断为非严重冠状动脉狭窄（即狭窄小于70%）的低至中度风险胸痛患者，后续心脏核素灌注成像的价值有限。
