Department of Cardiology, Jolimont Hospital, La Louviére, Belgium.
Department of Cardiology, University Hospital Erasme Brussels, Brussels, Belgium.
Acta Cardiol. 2022 Sep;77(7):602-608. doi: 10.1080/00015385.2021.1968154. Epub 2021 Sep 5.
To test the hypothesis that dobutamine stress echocardiography (DSE) reduces the rate of unnecessary invasive coronary angiography (CA) in patients with chronic stable coronary artery disease (CAD) and moderate to severe stenosis detected by coronary computed tomography angiography (CCTA).
This study included 49 consecutive, symptomatic CAD patients with coronary lesions greater than 50% detected by CCTA who underwent all DSE and a CA with pressure wire evaluation and FFR measurement. The DSE operators was aware of the CCTA results, but invasive physicians were blinded to DSE results. The primary endpoint was the negative predictive value of a CCTA followed by a DSE test for detecting significant coronary artery disease (CAD). This was defined by the presence of significant coronary lesions (>90% stenosis) or moderate coronary lesions (50-90%) with abnormal FFR value of less than 0.80 evaluated by invasive angiogram (CA). Secondary endpoints included major adverse cardiovascular events (MACEs).
In patients with abnormal CCTA followed by CA, 33 patients (67.34%) had non-significant CAD lesions. In patients with both abnormal CCTA and DSE only 6 patients (12.24%) presented non-significant CAD. The negative predictive value of a CCTA followed by a DSE was significantly increased to 92.5%, when compared with CCTA alone. Thus DSE on top of abnormal CCTA could reduce unnecessary CA by 5.5 fold. During follow-up (mean 38.75 ± 12.25 months) 1 (2.1%) patient had a cardiac sudden death, 3 (6.12%) patients had an unplanned myocardial revascularization and 1 (2.1%) patient had a stroke, none of which occurred in patients with normal DSE. No patients experienced a myocardial infarction or needed un unplanned surgical revascularization.
The addition of DSE in case of abnormal CCTA increases significantly the negative predictive value for detecting significant CAD in need for revascularisation and thus reduces markedly the number of unnecessary CA. This diagnostic strategy has a higher diagnostic accuracy and negative predictive value to the opposite approach where an abnormal CCTA mandates a CA without additional functional testing.
检验这样一个假设，即在通过冠状动脉计算机断层扫描血管造影术（CCTA）检测到患有慢性稳定型冠状动脉疾病（CAD）且狭窄程度为中度至重度的患者中，多巴酚丁胺负荷超声心动图（DSE）可降低不必要的有创冠状动脉造影（CA）的发生率。
本研究纳入了 49 例连续的、有症状的 CAD 患者，这些患者通过 CCTA 检测到了大于 50%的冠状动脉病变，且接受了所有 DSE 检查以及伴有压力导丝评估和 FFR 测量的 CA。DSE 操作者知晓 CCTA 结果，但介入医师对 DSE 结果不知情。主要终点是 CCTA 后 DSE 检测对检测到有意义的 CAD 的阴性预测值。这是通过有创血管造影（CA）评估发现存在有意义的冠状动脉病变（>90%狭窄）或中度冠状动脉病变（50-90%狭窄）和异常 FFR 值<0.80 来定义的。次要终点包括主要不良心血管事件（MACEs）。
在 CCTA 后 CA 异常的患者中，33 例（67.34%）患者存在非显著性 CAD 病变。在 CCTA 和 DSE 均异常的患者中，仅 6 例（12.24%）患者存在非显著性 CAD。与仅 CCTA 相比，CCTA 后 DSE 的阴性预测值显著升高至 92.5%。因此，在 CCTA 异常的基础上进行 DSE 可使不必要的 CA 减少 5.5 倍。在随访期间（平均 38.75±12.25 个月），1 例（2.1%）患者发生心脏性猝死，3 例（6.12%）患者进行了计划外血运重建，1 例（2.1%）患者发生了卒中，这些均未发生在 DSE 正常的患者中。无患者发生心肌梗死或需要计划外手术血运重建。
在 CCTA 异常的情况下，增加 DSE 可显著提高检测需要血运重建的显著 CAD 的阴性预测值，从而显著减少不必要的 CA。这种诊断策略比相反的方法（即异常 CCTA 要求进行 CA 而不进行额外的功能检查）具有更高的诊断准确性和阴性预测值。
