核心脏病学现状与进展a教学课件

1、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 DiseaseChanging rolesCoronary stenosis (coronary angiography, CTA)?myocardial ischemia (SPECT, PET, stress echo) ?Changing strategyAccuracy of Noninvasive Test for Diagnosis of CADNo. of StudiesNo. of PatientsSensitivit

2、ySpecificityExercise ECG147240476877Exercise Perfusion Imaging2287518980Pharmacological Stress Scintigraphy 11400EBT Baseline Calcium Score% with +SPECT(n=17)(n=37)(n=93)(n=89)(n=10)1-10246 patients allasymptomaticexcept 34 withatypical CP58 + 10 years75% with 2 ormore RFHe et. al Circulation 2000;1

3、01:244-51EBT Calcium Score and SPECT Thallium Stress TestingClinical Characteristics (N=706) of Patients who Underwent CTA and SPECT14N (%)/averageAge56.19.9Male450 (63.7%)Body Mass Index25.1*Diabetes102 (14.4)Hypertension388 (55.0)Hyperlipidemia407 (57.6)Smoking273 (38.7)Family History of CAD165 (2

4、3.4)SymptomsAsymptomatic118 (16.7)Atypical chest pain476 (67.4)Typical chest pain112 (15.9)Accuracy of luminal stenosis by coronary CTA for detecting abnormal MPI15StenosisSensitivity*Specificity*PPV*NPV*Patients Level50%80.256.721.595.175%48.490.442.792.290%29.798.47390.4Vascular Level50%69.679.315

5、.897.975%40.295.633.696.690%22.39954.395.8CTA and SPECT/ CTA for Detection of Hemodynamically Significant Coronary LesionsRispler JACC 2007; 49: 1059-67050100PercentSens Spec PPV NPVSens Spec PPV NPVCTASPECT/ CTA9696999963953177PET/CT in CADNamdar M, et al. JNM 2005Myocardial Infarctions are causedb

6、y Low-Grade StenosesPooled 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 StratificationLow 3% per year Adapted from Gibbons RJ, et al. J Am Coll Cardiol. 1999;33:2092-2197. Risk of Cardiac Death:Risk Stratif

7、ication: Noninvasive Testing Markers Amount of infarcted myocardium Amount of jeopardized myocardium Degree of jeopardy Risk Stratification: Noninvasive Testing MarkersLeft ventricular systolic function Predictors of cardiac mortalityfactors estimating the extent of LV dysfunction LVEFthe extent of

8、infarcted myocardiumtransient ischemic dilation of the LV and increased lung uptakePredictors of the subsequent development of acute ischemic syndromesmarkers of provocative ischemiaexertional symptoms,electrocardiographic changesthe extent of reversible perfusion defectsstress-induced ventricular d

9、yssynergyFollow-up Time (Months)9080706050403020100Cumulative Event-Free Survival1.0.9.8.7.6.5Normal CoronariesAngiographic CADp=nsYang MF, NMC, 2006Prognostic value: Perfusion imaging vs. AngiographyPatients with a normal stress myocardial perfusion imaging are at low risk for cardiac events (1% mo

10、rtality 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 AbnormalModerately AbnormalSeverely Abn

11、ormalNormal2946884455898Prognosis: MPI Scan Severity Predicts Outcome* P.001 *P.01nSSS13Cardiac Death Rate (%/y)Hachamovitch R, et al. Circulation 1998Enrollment and Outcomes3,071 Patients met protocol eligibility criteria2,287 Consented to Participate(74% of protocol-eligible patients)1,149 Were as

12、signed to PCI group 46 Did not undergo PCI 27 Had a lesion that could not be dilated1,006 Received at least one stent784 Did not provide consent- 450 Did not receive MD approval- 237 Declined to give permission- 97 Had an unknown reason107 Were lost to follow-up1,149 Were included in the primary ana

13、lysis1,138 Were assigned to medical-therapy group97 Were lost to follow-up1,138 Were included in the primary analysisShaw, L. J. et al. Circulation 2008;117:1283-1291Kaplan-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）31Han PP

14、, 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）32P0.001Han PP, et al. Chin J Med 2011 (in press)ACCF/SCAI/STS/AATS/AHA/ASNC 2009 Appropriateness Criteria for Coronary RevascularizationThe use of coronary revascularization for patients with acute coronary syndromes and combinations of significant symptoms and/