五洲会何作祥-核心脏病学现状与进展A-

核心脏病学现状与进展,何作祥国家心血管病中心中国医学科学院阜外心血管病医院,,2011年北京“五洲”心血管病研讨会,Imaging in Coronary Artery Disease,Changing rolesCoronary stenosis (coronary angiography, CTA)?myocardial ischemia (SPECT, PET, stress echo) ?Changing strategy,Accuracy of Noninvasive Test for Diagnosis of CAD,Circulation 2000;102:126,Gupta et al, 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,2005,Aden,Rest,Aden,Rest,Aden,Rest,Can Gated SPECT improve sensitivity for CAD detection?,Part 0. Introduction to Nuclear Medicine,9,ECG-GATED MYOCARDIAL PERFUSION,Gated SPECT vs. Cine MRI,Wang F, et al. Eur J Nucl Med Mol Imaging, 2009,Specificity of Stress TI-201 and Tc-99m Sestamibi SPECT for CAD Detection in Women,Stenosis 50% (n=51),Stenosis 70% (n=64),p=0.002,p=0.0004,p=0.05,NS,p=0.02,NS,Adapted from Taillefer et al. J Nucl Med 1996;37:69P.,70.6,86.3,94.1,67.2,84.4,92.2,Specificity (%),Examples of Coronary Artery Scans,Normal Condition,Moderate Calcification,Severe Calcification,0%,0%,2.7%,10.8%,48.3%,0,10,20,30,40,50,0,11-100,101-399,400,EBT Baseline Calcium Score,% with +SPECT,(n=17),(n=37),(n=93),(n=89),(n=10),1-10,246 patients allasymptomaticexcept 34 withatypical CP58 + 10 years75% with 2 ormore RF,He et. al Circulation 2000;101:244-51,EBT Calcium Score and SPECT Thallium Stress Testing,Clinical Characteristics (N=706) of Patients who Underwent CTA and SPECT,14,Accuracy of luminal stenosis by coronary CTA for detecting abnormal MPI,15,CTA and SPECT/ CTA for Detection of Hemodynamically Significant Coronary Lesions,Rispler JACC 2007; 49: 1059-67,0,50,100,Percent,Sens Spec PPV NPV,Sens Spec PPV NPV,CTA,SPECT/ CTA,96,96,99,99,63,95,31,77,PET/CT in CAD,Namdar M, et al. JNM 2005,Myocardial Infarctions are causedby Low-Grade Stenoses,Pooled data from 4 studies: Ambrose et al, 1988; Little et al, 1988; Nobuyoshi et al, 1991; and Giroud et al, 1992.(Adapted from Falk et al.),Risk Stratification,Low 3% per year,Adapted from Gibbons RJ, et al. J Am Coll Cardiol. 1999;33:2092-2197.,Risk of Cardiac Death:,Risk Stratification: Noninvasive Testing Markers,Amount of infarcted myocardium Amount of jeopardized myocardium Degree of jeopardy,Risk Stratification: Noninvasive Testing Markers,Left ventricular systolic function,Predictors of cardiac mortality,factors estimating the extent of LV dysfunction LVEFthe extent of infarcted myocardiumtransient ischemic dilation of the LV and increased lung uptake,Predictors of the subsequent development of acute ischemic syndromes,markers of provocative ischemiaexertional symptoms,electrocardiographic changesthe extent of reversible perfusion defectsstress-induced ventricular dyssynergy,Follow-up Time (Months),90,80,70,60,50,40,30,20,10,0,Cumulative Event-Free Survival,1.0,.9,.8,.7,.6,.5,Normal Coronaries,Angiographic CAD,p=ns,Yang MF, NMC, 2006,Prognostic value: Perfusion imaging vs. Angiography,Patients with a normal stress myocardial perfusion imaging are at low risk for cardiac events (1% mortality per year), even in the presence of angiographically significant coronary artery stenosis.,2.9,0.3,0.8,2.3,0.5,2.7,2.9,4.2,0.0,1.0,2.0,3.0,4.0,5.0,Event Rate/Year, %,Cardiac Death,MI,Hachamovitch R, et al. Circulation. 1998;97:535-543.,Scan Result,*,*,*,Mildly Abnormal,Moderately Abnormal,Severely Abnormal,Normal,2946,884,455,898,Prognosis: MPI Scan Severity Predicts Outcome,* P.001 *P.01,n,SSS,13,Cardiac Death Rate (%/y),Hachamovitch R, et al. Circulation 1998,Enrollment and Outcomes,3,071 Patients met protocol eligibility criteria,2,287 Consented to Participate(74% of protocol-eligible patients),1,149 Were assigned to PCI group 46 Did not undergo PCI 27 Had a lesion that could not be dilated1,006 Received at least one stent,784 Did not provide consent- 450 Did not receive MD approval- 237 Declined to give permission- 97 Had an unknown reason,107 Were lost to follow-up,1,149 Were included in the primary analysis,1,138 Were assigned to medical-therapy group,97 Were lost to follow-up,1,138 Were included in the primary analysis,Shaw, L. J. et al. Circulation 2008;117:1283-1291,Kaplan-Meier survival for patients by residual ischemia after 6 to 18 months of PCI+OMT or OMT,心肌SPECT正常与异常患者的冠状动脉造影率对比（N=1053）,31,Han PP, et al. Chin J Med 2011 (in press),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）,32,P0.001,Han PP, et al. Chin J Med 2011 (in press),ACCF/SCAI/STS/AATS/AHA/ASNC 2009 Appropriateness Criteria for Coronary Revascularization,The use of coronary revascularization for patients with acute coronary syndromes and combinations of significant