左束支传导阻滞患者左前降支冠状动脉狭窄的检测：运动、腺苷还是多巴酚丁胺成像？

Detection of left anterior descending coronary artery stenosis in patients with left bundle branch block: exercise, adenosine or dobutamine imaging?

作者信息

Vaduganathan P, He Z X, Raghavan C, Mahmarian J J, Verani M S

机构信息

Section of Cardiology, Baylor College of Medicine, Houston, Texas, USA.

出版信息

J Am Coll Cardiol. 1996 Sep;28(3):543-50. doi: 10.1016/0735-1097(96)00224-0.

DOI:10.1016/0735-1097(96)00224-0

PMID:8772737

Abstract

OBJECTIVES

This study sought to assess the diagnostic value of myocardial perfusion imaging during exercise and pharmacologic stress in patients with left bundle branch block.

BACKGROUND

Patients with left bundle branch block often have septal perfusion defects during exercise perfusion tomography that mimic defects caused by coronary artery disease. These defects appear to be less frequent during pharmacologic stress using adenosine or dipyridamole. Data are scantly on the value of dobutamine tomography in these patients.

METHODS

We studied 383 consecutive patients with left bundle branch block referred for perfusion scintigraphy over a 5-year span. Perfusion tomography was performed in conjunction with exercise in 206 patients, adenosine in 127 and dobutamine in 50. Coronary angiography was performed within 1 month of the nuclear study in 77, 50 and 27 patients, respectively.

RESULTS

Exercise, adenosine and dobutamine tomography had similar sensitivity and specificity for the detection of > 50% stenosis in the left circumflex (74% and 96%; 50% and 100%; 63% and 91%, respectively) and right coronary arteries (96% and 86%; 82% and 91%; 79% and 100%, respectively) and similar sensitivity for left anterior descending coronary artery stenosis (88%, 79% and 100%, respectively). However, the false-positive rate for septal defects was higher by exercise tomography (26 [46%] of 57) than by pharmacologic methods (5 [10%] of 48, p < 0.001), and there was no significant difference between adenosine (4 [11%] of 35) and dobutamine (1 [8%] of 13, p = 0.7). The specificity and predictive value of a positive test response for left anterior descending coronary artery stenosis were 36% and 51% for exercise compared with 81% and 85% for adenosine (p < or = 0.001) and 80% and 90% for dobutamine (p < 0.05), respectively.

CONCLUSIONS

In patients with left bundle branch block, pharmacologic stress is more specific than exercise tomography in the diagnosis of left anterior descending coronary artery stenosis. Dobutamine and adenosine tomography appear to be equally specific in these patients.

摘要

目的

本研究旨在评估运动及药物负荷心肌灌注成像对左束支传导阻滞患者的诊断价值。

背景

左束支传导阻滞患者在运动灌注断层扫描时经常出现室间隔灌注缺损，类似冠状动脉疾病所致的缺损。使用腺苷或双嘧达莫进行药物负荷时，这些缺损似乎较少见。关于多巴酚丁胺断层扫描在这些患者中的价值的数据很少。

方法

我们对连续383例因灌注闪烁扫描而转诊的左束支传导阻滞患者进行了为期5年的研究。206例患者在运动时进行灌注断层扫描，127例使用腺苷，50例使用多巴酚丁胺。分别有77例、50例和27例患者在核素检查后1个月内进行了冠状动脉造影。

结果

运动、腺苷和多巴酚丁胺断层扫描对检测左旋支和右冠状动脉>50%狭窄的敏感性和特异性相似（左旋支分别为74%和96%、50%和100%、63%和91%；右冠状动脉分别为96%和86%、82%和91%、79%和100%），对左前降支冠状动脉狭窄的敏感性相似（分别为88%、79%和100%）。然而，运动断层扫描时室间隔缺损的假阳性率（57例中的26例[46%]）高于药物负荷方法（48例中的5例[10%]，p<0.001），腺苷（35例中的4例[11%]）和多巴酚丁胺（13例中的1例[8%]，p = 0.7）之间无显著差异。运动时左前降支冠状动脉狭窄阳性试验反应的特异性和预测价值分别为36%和51%，而腺苷分别为81%和85%（p≤0.001），多巴酚丁胺分别为80%和90%（p<0.05）。