Haberkorn Sebastian M, Haberkorn Sandra I, Bönner Florian, Kelm Malte, Hopkin Gareth, Petersen Steffen E
Department of Cardiology, Pneumology and Angiology, University Hospital Düsseldorf, Düsseldorf, Germany.
Department of Health Policy, London School of Economics and Political Science, London, United Kingdom.
Front Cardiovasc Med. 2021 Mar 12;8:630846. doi: 10.3389/fcvm.2021.630846. eCollection 2021.
Guideline recommendations for patients with either a high or a low risk of obstructive coronary artery disease (CAD) are clear. However, the evidence for initial risk stratification in patients with an intermediate risk of CAD is still unclear, despite the availability of multiple non-invasive assessment strategies. The aim of this study was to synthesize the evidence for this population to provide more informed recommendations. A meta-analysis was performed to systematically assess the diagnostic accuracy of vasodilator myocardial perfusion cardiovascular magnetic resonance imaging (pCMR) and dobutamine stress echocardiography (DSE) for the detection of relevant CAD. In contrast to previous work, this meta-analysis follows rigorous selection criteria in regards to the risk stratification and a narrowly prespecified definition of their invasive reference tests, resulting in unprecedentedly informative results for this reference group. From the 5,634 studies identified, 1,306 relevant articles were selected after title screening and further abstract screening left 865 studies for full-text review. Of these, 47 studies fulfilled all inclusion criteria resulting in a total sample size of 4,742 patients. pCMR studies showed a superior sensitivity [0.88 (95% confidence interval (CI): 0.85-0.90) vs. 0.72 (95% CI: 0.61-0.81)], diagnostic odds ratio (DOR) [38 (95% CI: 29-49) vs. 20 (95% CI: 9-46)] and an augmented post-test probability [negative likelihood ratio (LR) of 0.14 (95% CI: 0.12-0.18) vs. 0.31 (95% CI: 0.21, 0.46)] as compared to DSE. Specificity was statistically indifferent [0.84 (95% CI: 0.81-0.87) vs. 0.89 (95% CI: 0.83-0.93)]. The results of this systematic review and meta-analysis suggest that pCMR has a superior diagnostic test accuracy for relevant CAD compared to DSE. In patients with intermediate risk of CAD only pCMR can reliably rule out relevant stenosis. In this risk cohort, pCMR can be offered for initial risk stratification and guidance of further invasive treatment as it also rules in relevant CAD.
对于阻塞性冠状动脉疾病（CAD）高风险或低风险患者的指南建议很明确。然而，尽管有多种非侵入性评估策略，但CAD中度风险患者初始风险分层的证据仍不明确。本研究的目的是综合该人群的证据，以提供更明智的建议。进行了一项荟萃分析，以系统评估血管扩张剂心肌灌注心血管磁共振成像（pCMR）和多巴酚丁胺负荷超声心动图（DSE）检测相关CAD的诊断准确性。与以往的研究不同，这项荟萃分析在风险分层方面遵循严格的选择标准，并对其侵入性参考测试进行了狭义的预先定义，从而为该参考组带来了前所未有的丰富信息结果。在识别出的5634项研究中，经过标题筛选后选择了1306篇相关文章，进一步的摘要筛选留下865项研究进行全文审查。其中，47项研究符合所有纳入标准，总样本量为4742例患者。pCMR研究显示出更高的敏感性[0.88（95%置信区间（CI）：0.85-0.90）对0.72（95%CI：0.61-0.81）]、诊断比值比（DOR）[38（95%CI：29-49）对20（95%CI：9-46）]和更高的验后概率[阴性似然比（LR）为0.14（95%CI：0.12-0.18）对0.31（95%CI：0.21，0.46）]，与DSE相比。特异性在统计学上无差异[0.84（95%CI：0.81-0.87）对0.89（95%CI：0.83-0.93）]。这项系统评价和荟萃分析的结果表明，与DSE相比，pCMR对相关CAD具有更高的诊断测试准确性。在CAD中度风险患者中，只有pCMR能够可靠地排除相关狭窄。在这个风险队列中，pCMR可用于初始风险分层和进一步侵入性治疗的指导，因为它也能诊断出相关CAD。
