五洲会何作祥-核心脏病学现状与进展a-课件

核心脏病学现状与进展国家心血管病中心2011年北京“五洲”心血管病研讨会Imaging

inCoronaryArteryDiseaseChangingrolesCoronarystenosis(coronaryangiography,CTA)?myocardialischemia(SPECT,PET,stressecho)?ChangingstrategyAccuracyofNoninvasiveTestforDiagnosisofCADNo.ofStudiesNo.ofPatientsSensitivitySpecificityExerciseECG147240476877ExercisePerfusionImaging2287518980PharmacologicalStressScintigraphy11<10008591Circulation2000;102:126Guptaetal,1992腺苷负荷试验心肌灌注显像多中心临床试验田月琴,等,中华心血管病杂志,2005AdenRestAdenRestAdenRestPart0.IntroductiontoNuclearMedicine9ECG-GATEDMYOCARDIALPERFUSIONGatedSPECTvs.CineMRIWangF,etal.EurJNuclMedMolImaging,2009SpecificityofStressTI-201andTc-99mSestamibi

SPECTforCADDetectioninWomenStenosis50%(n=51)Stenosis70%(n=64)p=0.002p=0.0004p=0.05NSp=0.02NSAdaptedfromTailleferetal.JNuclMed1996;37:69P.70.686.394.167.284.492.20102030405060708090100Tl-201Tc-99m

SestamibiGatedTc-99m

SestamibiSpecificity(%)0%0%2.7%10.8%48.3%01020304050011-100101-399>400EBTBaselineCalciumScore%with+SPECT(n=17)(n=37)(n=93)(n=89)(n=10)1-10246patientsallasymptomaticexcept34withatypicalCP58+10years75%with2ormoreRFHeet.alCirculation2000;101:244-51EBTCalciumScoreandSPECTThalliumStressTestingClinicalCharacteristics(N=706)ofPatientswhoUnderwentCTAandSPECT14N(%)/averageAge56.1±9.9Male450(63.7%)BodyMassIndex25.1*Diabetes102(14.4)Hypertension388(55.0)Hyperlipidemia407(57.6)Smoking273(38.7)FamilyHistoryofCAD165(23.4)SymptomsAsymptomatic118(16.7)Atypicalchestpain476(67.4)Typicalchestpain112(15.9)AccuracyofluminalstenosisbycoronaryCTAfordetectingabnormalMPI15StenosisSensitivity*Specificity*PPV*NPV**Patients’Level≥50%80.256.721.595.1≥75%48.490.442.792.2≥90%29.798.47390.4VascularLevel≥50%69.679.315.897.9≥75%40.295.633.696.6≥90%22.39954.395.8PET/CTinCADNamdarM,etal.JNM2005MyocardialInfarctionsarecaused

byLow-GradeStenosesPooleddatafrom4studies:Ambroseetal,1988;Littleetal,1988;Nobuyoshietal,1991;andGiroudetal,1992.

(AdaptedfromFalketal.)RiskStratificationLow

<1%peryearIntermediate

1-3%peryearHigh

>3%peryearAdaptedfromGibbonsRJ,etal.JAmCollCardiol.1999;33:2092-2197.RiskofCardiacDeath:RiskStratification:

NoninvasiveTestingMarkersLeftventricularsystolicfunctionPredictorsofcardiacmortalityfactorsestimatingtheextentofLVdysfunctionLVEFtheextentofinfarctedmyocardiumtransientischemicdilationoftheLVandincreasedlunguptakePredictorsofthesubsequent

developmentofacute

ischemicsyndromesmarkersofprovocativeischemiaexertionalsymptoms,electrocardiographicchangestheextentofreversibleperfusiondefectsstress-inducedventriculardyssynergyFollow-upTime(Months)9080706050403020100CumulativeEvent-FreeSurvival.7.6.5NormalCoronariesAngiographicCADp=nsYangMF,NMC,2006Prognosticvalue:

Perfusionimagingvs.AngiographyPatientswithanormalstressmyocardialperfusionimagingareatlowriskforcardiacevents(<1%mortalityperyear),eveninthepresenceofangiographicallysignificantcoronaryarterystenosis.EnrollmentandOutcomes3,071Patientsmetprotocoleligibilitycriteria2,287ConsentedtoParticipate(74%ofprotocol-eligiblepatients)1,149WereassignedtoPCIgroup46DidnotundergoPCI27Hadalesionthatcouldnotbedilated1,006Receivedatleastonestent784Didnotprovideconsent-450DidnotreceiveMDapproval-237Declinedtogivepermission-97Hadanunknownreason107Werelosttofollow-up1,149Wereincludedintheprimaryanalysis1,138Wereassignedtomedical-therapygroup97Werelosttofollow-up1,138WereincludedintheprimaryanalysisShaw,L.J.etal.Circulation2008;117:1283-1291Kaplan-Meiersurvivalforpatientsbyresidualischemia

after6to18monthsofPCI+OMTorOMT心肌SPECT正常与异常患者的冠状动脉造影率对比（N=1053）31HanPP,etal.ChinJMed2011(inpress)心肌灌注显像正常与异常的冠状动脉再血管化治疗比例（N=1053）32P<0.001HanPP,etal.ChinJMed2011(inpress)ACCF/SCAI/STS/AATS/AHA/ASNC2009Appropriateness

CriteriaforCoronary

RevascularizationTheuseofcoronaryrevascularizationforpatients

withacutecoronarysyndromesandcombinationsofsignificant

symptomsa