冠状动脉计算机断层扫描血管造影术与功能测试在诊断阻塞性冠状动脉疾病中的有效性：来自心脏CT个体患者数据协作荟萃分析（COME-CCT）的结果
The effectiveness of coronary computed tomography angiography and functional testing for the diagnosis of obstructive coronary artery disease: results from the individual patient data Collaborative Meta-Analysis of Cardiac CT (COME-CCT).
作者信息
Schlattmann Peter, Wieske Viktoria, Bressem Keno K, Götz Theresa, Schuetz Georg M, Andreini Daniele, Pontone Gianluca, Alkadhi Hatem, Hausleiter Jörg, Zimmermann Elke, Gerber Bernhard, Shabestari Abbas A, Meijs Matthijs F L, Sato Akira, Øvrehus Kristian A, Jenkins Shona M M, Knuuti Juhani, Hamdan Ashraf, Halvorsen Bjørn A, Mendoza-Rodriguez Vladimir, Rixe Johannes, Wan Yung-Liang, Langer Christoph, Leschka Sebastian, Martuscelli Eugenio, Ghostine Said, Tardif Jean-Claude, Sánchez Alejandra Rodríguez, Haase Robert, Dewey Marc
机构信息
Institute of Medical Statistics, Computer Sciences, and Data Science, University Hospital of Friedrich Schiller University Jena, Jena, Germany.
Department of Radiology, Charité-Universitätsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Germany.
出版信息
Insights Imaging. 2024 Aug 14;15(1):208. doi: 10.1186/s13244-024-01702-y.
AIM
To determine the effectiveness of functional stress testing and computed tomography angiography (CTA) for diagnosis of obstructive coronary artery disease (CAD).
METHODS AND RESULTS
Two-thousand nine-hundred twenty symptomatic stable chest pain patients were included in the international Collaborative Meta-Analysis of Cardiac CT consortium to compare CTA with exercise electrocardiography (exercise-ECG) and single-photon emission computed tomography (SPECT) for diagnosis of CAD defined as ≥ 50% diameter stenosis by invasive coronary angiography (ICA) as reference standard. Generalised linear mixed models were used for calculating the diagnostic accuracy of each diagnostic test including non-diagnostic results as dependent variables in a logistic regression model with random intercepts and slopes. Covariates were the reference standard ICA, the type of diagnostic method, and their interactions. CTA showed significantly better diagnostic performance (p < 0.0001) with a sensitivity of 94.6% (95% CI 92.7-96) and a specificity of 76.3% (72.2-80) compared to exercise-ECG with 54.9% (47.9-61.7) and 60.9% (53.4-66.3), SPECT with 72.9% (65-79.6) and 44.9% (36.8-53.4), respectively. The positive predictive value of CTA was ≥ 50% in patients with a clinical pretest probability of 10% or more while this was the case for ECG and SPECT at pretest probabilities of ≥ 40 and 28%. CTA reliably excluded obstructive CAD with a post-test probability of below 15% in patients with a pretest probability of up to 74%.
CONCLUSION
In patients with stable chest pain, CTA is more effective than functional testing for the diagnosis as well as for reliable exclusion of obstructive CAD. CTA should become widely adopted in patients with intermediate pretest probability.
SYSTEMATIC REVIEW REGISTRATION
PROSPERO Database for Systematic Reviews-CRD42012002780.
CRITICAL RELEVANCE STATEMENT
In symptomatic stable chest pain patients, coronary CTA is more effective than functional testing for diagnosis and reliable exclusion of obstructive CAD in intermediate pretest probability of CAD.
KEY POINTS
Coronary computed tomography angiography showed significantly better diagnostic performance (p < 0.0001) for diagnosis of coronary artery disease compared to exercise-ECG and SPECT. The positive predictive value of coronary computed tomography angiography was ≥ 50% in patients with a clinical pretest probability of at least 10%, for ECG ≥ 40%, and for SPECT 28%. Coronary computed tomography angiography reliably excluded obstructive coronary artery disease with a post-test probability of below 15% in patients with a pretest probability of up to 74%.
目的
确定功能应激试验和计算机断层扫描血管造影（CTA）对诊断阻塞性冠状动脉疾病（CAD）的有效性。
方法与结果
国际心脏CT联合荟萃分析纳入了2920例有症状的稳定型胸痛患者，以有创冠状动脉造影（ICA）定义的≥50%管径狭窄为参考标准，比较CTA与运动心电图（运动-ECG）及单光子发射计算机断层扫描（SPECT）对CAD的诊断效果。采用广义线性混合模型计算各诊断试验的诊断准确性，将非诊断结果作为逻辑回归模型中的因变量，该模型具有随机截距和斜率。协变量为参考标准ICA、诊断方法类型及其相互作用。与运动-ECG相比，CTA显示出显著更好的诊断性能（p<0.0001），敏感性为94.6%（95%CI 92.7-96），特异性为76.3%（72.2-80），而运动-ECG的敏感性为54.9%（47.9-61.7），特异性为60.9%（53.4-66.3）；SPECT的敏感性为72.9%（65-79.6），特异性为44.9%（36.8-53.4）。临床预测试概率为10%或更高的患者中，CTA的阳性预测值≥50%，而对于ECG和SPECT，预测试概率≥40%和28%时才是这种情况。预测试概率高达74%的患者中，CTA能可靠地排除阻塞性CAD，测试后概率低于15%。
结论
对于稳定型胸痛患者，CTA在诊断以及可靠排除阻塞性CAD方面比功能测试更有效。CTA应在预测试概率中等的患者中广泛应用。
系统评价注册
系统评价的PROSPERO数据库-CRD42012002780。
关键相关性声明
在有症状的稳定型胸痛患者中，对于CAD预测试概率中等的患者，冠状动脉CTA在诊断和可靠排除阻塞性CAD方面比功能测试更有效。
要点
与运动-ECG和SPECT相比，冠状动脉计算机断层扫描血管造影在诊断冠状动脉疾病方面显示出显著更好的诊断性能（p<0.0001）。临床预测试概率至少为10%的患者中，冠状动脉计算机断层扫描血管造影的阳性预测值≥50%，ECG为≥40%，SPECT为28%。预测试概率高达74%的患者中，冠状动脉计算机断层扫描血管造影能可靠地排除阻塞性冠状动脉疾病，测试后概率低于15%。
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