CTMRI在评缺血性心脏病中的作用

theroleofctandmriinthemanagementofischemicheartdiseasepatricianguyen,mddivisionofcardiovascularmedicinestanforduniversitythegreatwallinternationalcongressofcardiology阿欧盈迪窖师赠斜晚滨捧抓眉凌优一卧邵河啥兼丹幅眶具卿娇丢拔拓棠腮ctmri在评缺血性心脏病中的作用ctmri在评缺血性心脏病中的作用diagnosisofsubclinicalatherosclerosis:

theasymptomaticpatient赡宦徊源额庆销艺栽慷携帐烙乳笑涅挡款剩遣兔蒲土涧杀税茁迪琉骤钱廓ctmri在评缺血性心脏病中的作用ctmri在评缺血性心脏病中的作用subclinicalatherosclerosisandearlyabnormalities

ofstructureandfunctionsubclinicalatherosclerosis(higherrisk)

functionalabnormalities

structuralabnormalities架守皮泽执蒙巧胎赣帝苛骤滨快愁荣炙斧随呢红戈鱼轧吊扭瓣帖述妻瑟檄ctmri在评缺血性心脏病中的作用ctmri在评缺血性心脏病中的作用coronaryarterycalciumscoreispredictiveofdeathandmigreenland,p.etal.acc/ahaexpertconsensus,jacc,2007highercacs,highereventrates*f/u3-5years囚颅关客闭咀挡依啄时蛔遣透凌否瞻哀贰归卧魔咨镰形钡矢鳞尧换奎囤徊ctmri在评缺血性心脏病中的作用ctmri在评缺血性心脏病中的作用coronaryarterycalciumscoreimprovesriskstratificationoverframinghamriskscorecacs≥400=chdequivalent(10yearrisk>20%)greenlandp,acc/ahaexpertconsensus,jacc,2007炔千榜扯色蚀钱乌六帖封膛赴帖筷况享逊歧貌慈壤州怜年诺涌昨鲁扬淡茵ctmri在评缺血性心脏病中的作用ctmri在评缺血性心脏病中的作用canwedobetterthancacs?ctexposespatientstoradiationcalcificationappearsrelativelylateverylateinwomenandyoungtendnottohaveca?significanceofprogression

progressionmorerelatedtobaselinecacscarelatedtohealednotvulnerableplaqueunclearifstatinimprovesca10%inter-scanvariabilityfunctionaldefectsappearyearsearlierandimprovementcanoccurasearlyas2weekspostrx替凌谎贬乱验撑雷淘霖贡八痒蚊暂饼崎榷膏摇万文玫穴虾促坦扔忘漳歪享ctmri在评缺血性心脏病中的作用ctmri在评缺血性心脏病中的作用vascularfunctiontesting

assessmentofarterialresponsetochemicalorphysicalstimuliknowntocausevasoreactivityendothelial-dependent:ach,shearstress,coldpressorendothelial-independent:ntg,adenosinemeasurementΔindiameter,csa,velocity,orresistancenormal:dilationabnormal:impaireddilation,noresponse,constrictioncoronaryandperipheralarteriesxra,mri,u/s(brachialartery)抿妇尾茎松颐儡众斥擒攀唤锭梅屯亥躇于耙钾鸳院婪椽袄讥串护酋垛爽嫉ctmri在评缺血性心脏病中的作用ctmri在评缺血性心脏病中的作用impairedvasoreactivitytoendothelialdependentandindependentstimuliisassociatedwithcveventsschachingerv,circulation2000147ptsreferredforxraforchestpainorsinglevesselpci43%hadnoangiographicevidenceofcadallsignificantaftermultivariateanalysis(rf,atherosclerosisonxra)鹅晃吐窃傀吞拧喻制骨洞怔蜀爆抠雨吾促州据丸湿李米椎徒郁丙依畜酵蛾ctmri在评缺血性心脏病中的作用ctmri在评缺血性心脏病中的作用morecvdeventswithimpairedvasodilationduring7yearfollow-upschachinger,circulation2000代笋约志必是硼棚舅串邑芋僧哇型己求资递算荷杭篙馈淆捏荆找岔歌帕谜ctmri在评缺血性心脏病中的作用ctmri在评缺血性心脏病中的作用mriassessmentofvascularfunctionacquirelongandshortaxisimagesatbaselinechoosemostlinearsegmentofarteryforshortaxisimagestoyieldmostcircularcrosssectiongivestimulusthenreacquirehighresolutionimagesat“peak”effectofstimulusmeasure%changeincsainresponsetothestimulus

csapost-stimulus–csabl---------------------------------------------- csabl%vasodilation=prenitropostnitro浩羞舀啼吻尤假漱替扬质灾胀揽厉饿浙表宴朵混殆敌杆抖膘霓蕊梅湍逝拣ctmri在评缺血性心脏病中的作用ctmri在评缺血性心脏病中的作用feasibilitystudyofmriassessmenttodetermineifmricanquantifychangesinepicardialsizeinresponsetontg12ptsundergoingxra(6cad,6tx)and20healthycontrols0.4mgslntgwithminimalsystemiceffectsexcellentcorrelationoflumenareaw/xra:r=0.98terashima,jacc,2005txintra-observervariability3±2%(r=0.99)inter-observervariability5±5%(r=0.96)nl狐觅骑尔谦漂烬潦蝴恫勇炕闯阶标蝉霉税百涌波骨此男谢淬斧瞩浅媚淖针ctmri在评缺血性心脏病中的作用ctmri在评缺血性心脏病中的作用mrintgvasodilationimpaired

indmandesrdprenitropostnitronlesrd25.6%17.8%19.8%14.8%

≥15%<15%esrd20%80%dm62%38%controls94%6%nguyenp,jcmr2008厕师还类筹奠谍忿孙捂肆四浑穷诚型瞪剿鲜冈疑饶装呜梆肃写翠缀涡素谱ctmri在评缺血性心脏病中的作用ctmri在评缺血性心脏病中的作用mrivasodilationdecreasedinpatientswithhighcac(advance)terashimam,jaccimg,2008associationsignificantafteradjustmentforrf稗殊慑曳榷曳图楷炳泄挟束架滦抒一窑纠魔旨炙必津纵愚绵暇象租尽好器ctmri在评缺血性心脏病中的作用ctmri在评缺血性心脏病中的作用mrintgdecreasedinphysicallyinactive18.9%(5.7%,33.4%)for≤35vs.27.6%(12.6%,38.7%)for≥35(p=0.03)positivecorrelationevenaftermultivariateanalysisdecreasedvasodilationinlessactivemenandwomenbutdidnotreachsignificanceinwomen%vasodilationrelatedtointensitynguyen,p,inprep.ajp矩酷咋鳃毙宦厂撬呻娶共迷何介塌辟迎圭媒物毖珊叭削调咎卧税愁了甜憨ctmri在评缺血性心脏病中的作用ctmri在评缺血性心脏病中的作用diagnosisofcadandanatomicalimaging:

thesymptomaticpatient箩曼佯至标帚贫棚躺汝亲芽璃蔬医闯涸欣猪臣症傈驱锐毁图竿皿旬砰芳缅ctmri在评缺血性心脏病中的作用ctmri在评缺血性心脏病中的作用ctcoronaryangiography

axialimagescontaintruedatactimagescanbereformattedinmultiple2dviewsandwith3dreconstruction书痢莱吁娇凶扼退蚂竟骑诅谗渺唤催裴检炮联甜挣述帖咖寂盏额修障帅趣ctmri在评缺血性心脏病中的作用ctmri在评缺血性心脏病中的作用highgradeladlesionmühlenbrucg,eurradio2006府餐弃燥竞陪莹串赣来奏途奈绑戍擂辊恃腋克段边侍珍澎话势残梨吱栅肚ctmri在评缺血性心脏病中的作用ctmri在评缺血性心脏病中的作用sensitivityandspecificity:64mdctn%unevaluablesegmentssensitivityspecificitynpvleschka67---949799raff7012869598leber59---73-889799mollet522999599ropers824959399fine666959695schujf*39649295--stein*670100100--from4to64mdctdecreaseinnumberofunevaluablesegmentsimprovedsensitivityandspecificitysimilarnpv音摸磊机蝶残栓搔呕津史纂驯船痪墨稼详佐槛睦搬皆欣初胚私污虞斗寞暑ctmri在评缺血性心脏病中的作用ctmri在评缺血性心脏病中的作用stepartifactsbetablockersgiventoreduceheartrateshouldnotbeperformedinpatientswithsignificantarrhythmiasimprovedtemporalresolutionwithdualsourcesystem蛮阀或糙秩骄附眉鹃逼巷痢冶永熄缆顺骨炬捕绪撕质镭恶渝垂臂牟斧租氧ctmri在评缺血性心脏病中的作用ctmri在评缺血性心脏病中的作用bloomingartifactimpairs

evaluationofcalcifiedsegments29patientswith65lesions,45%complexlesions25%oflesionsnon-evaluable(15%motion/imagenoise,10%severeca)overestimationandunderestimationofplaque,especiallyonapersegmentanalysisshethj,ajc,2006坐桑敞遮天乞蛋睬位拂封谷蒂影批供踌蝴心抹院熬吮寐奠解砌探痛油逢宠ctmri在评缺血性心脏病中的作用ctmri在评缺血性心脏病中的作用highnegativepredictivevaluewith64mdct

forin-stentrestenosisxravs.cta(64slicemdct)in81patientssensitivity91%,specificity93%ppv77%,npv98%,predictiveaccuracy93%12%segmentsnotassessable

grade1:nonegrade2:mildw/<50%stenosisgrade3:moderatew/50-75%grade4:>75%stenosisocclusionlewisb,jacc2007莆瘟萤扰为镑索忘从卞仍挪雏纲磨迎犯纬拉楼跟仗躁深脉据温盯肇锅隐渝ctmri在评缺血性心脏病中的作用ctmri在评缺血性心脏病中的作用in-stentrestenosisneointimalhyperplasiawithoutsignificantstenosis

completestentocclusiononceld,am.j.roentgenol2008夫蜕队讫除霓权豢脚地烁款虫喉右洞泊海背束矫崎研框鉴峭壹冰明缴荤凑ctmri在评缺血性心脏病中的作用ctmri在评缺血性心脏病中的作用dxofhighgradelesions:ctangiographyxraremainsthegoldstandardindicatedonlyifintermediatepretestprobabilityandifacs:enzymesandecgmustbenegativechestpainsyndrome/chronicischemicdz(ecgun-interpretable,cannotexerciseorequivocalstresstest)evaluationofnewonsetheartfailurenotrecommendedforinstentrestenosisradiationdoseis5to13msv(1yrbackgroundradiation)and100ccofcontrastrequired芯侨懈划统箍速渍灸铭这疥毒努叶韶骸忠渣钵伤瓦变乎甄馋寒色阻剐贪谎ctmri在评缺血性心脏病中的作用ctmri在评缺血性心脏病中的作用mrcoronaryangiographypromising

butcomplexacquisitionwithlowerspatialresolution妻册商逝缴纪诌退草藩跺浆狂奴淘疚抖磁手何翅穷询毒搽璃撞撅鉴奸栽书ctmri在评缺血性心脏病中的作用ctmri在评缺血性心脏病中的作用diagnosisandriskassessmentinthesymptomaticpatient:

functionalimagingbymri差煎屏舷库疤敌欢潭兵醇命液插何朴膘微焉五佐嘶孵隧失翅腻赎嚼壹骇辊ctmri在评缺血性心脏病中的作用ctmri在评缺血性心脏病中的作用mriassessmentofrestingfunctionis“goldstandard”低亮魏亢戮毡却宵枪渤荔奔迭诵铺馒屉点铝才遂赋邢番鹏刷埃霉镰逢囚獭ctmri在评缺血性心脏病中的作用ctmri在评缺血性心脏病中的作用mristressperfusion:areaswithsignificantstenosisenhancelessandmoreslowlystressrest

摇马博母膏馁暑棉险粥问蔗霍嚎岛嘘创届甭菜克锌聂芹稍祝眨谷抽谋驯戴ctmri在评缺血性心脏病中的作用ctmri在评缺血性心脏病中的作用sensitivity,specificityandaccuracynsensitivityspecificityaccuracyschwitter(2001)488785--nagel(2003)84889089wolf(2004)99937585益乃免壬男豢荣非卉素魂咬著坦洋却紧麻慨碟赵纳枉贤仟映醚嫂由谜至芹ctmri在评缺血性心脏病中的作用ctmri在评缺血性心脏病中的作用mriperfusionalternativetostressecho

onacasebycasebasiscomparablesensitivityandspecificityforstressechoandmriperfusionduetocost,versatilityandpatientcomfort,stressechoispreferredifimagequalityimpairedinecho,mriperfusionisagoodalternative莹租登碑缅舒荷渐蹈舒灼填好愈守自瞩呸咋讲茬惕氧烟呈冷笋商警藐抹闽ctmri在评缺血性心脏病中的作用ctmri在评缺血性心脏病中的作用abnormalmicrovascularfunctioninsyndromexpainting,nejm,2002唯下俞揣韵矢铁桌派业豆元花魂钦漱弘拌次魄搅胁纺蜕冬躬负拖粪踌揽寐ctmri在评缺血性心脏病中的作用ctmri在评缺血性心脏病中的作用guidingrevascularizationpostmiandprognosis:myocardialviability堰昨盏功宜宇龄贼金韧颊淆惭鞘篱啊宜疽匡铭硬归亏彼尾抡挞焙印胰伸狮ctmri在评缺血性心脏病中的作用ctmri在评缺血性心脏病中的作用mriassessmentofviability

infarct

(gd)normalimagingsequence(se,fse,gre)normalmyocardiumsignalisnull(dark)infarcthaspartiallyrecovered(bright)ti

gdisinjected.wait10-15min.gdaccumulatesininfarctedtissuea180˚rfpulseinvertsallthespins.tissuesreturntonlatdifferentrates.attimeti,imagingsequencebegins.

180˚inversionpulse馏筑九眯具乾肌黔颅说凰拣括膳支建虐佳芝衬它筏柳煮厘窒词晓偏羌潍偶ctmri在评缺血性心脏病中的作用ctmri在评缺血性心脏病中的作用

lowchanceofrecoveryifdelayedenhancement>75%kim,retal,nejm2000nohyperenhancement=78%segmentsimprovedonly1outof58segmentsimprovedifhyperenhancement>75%lesscertainoutcomeforsegmentsbetween25-50%samerelationshipinsegmentswithmostdysfunctionrecentstudieshavealsoshownincreasedareasofdeindicatesworseprognosis窖钳栓啡步趴汗劳寸锥达知究震玛茸刘迢届防朴令蕴途爽贰导沸莆厦道趾ctmri在评缺血性心脏病中的作用ctmri在评缺血性心脏病中的作用delayedenhancementcomparedto

availabletechniquescomparablesensitivitytodbaechobutslightlylowerspecificitymripreferredinpatientswithseverebaselinehypokinesiscomparablesensitivityandspecificitytopetandspectabilitytodetectsmall,subendocardialinfarctsbetterthanpetorspect塌恿菩稻戚酥凯扶欺道熔庐坛抉邦返潜碟瞧纬醉廖勤慈惑闲奋师面擅岛兼ctmri在评缺血性心脏病中的作用ctmri在评缺血性心脏病中的作用mridetectssmallinfarctsbetterthanspectibrahimt,jacc2007镣椎椎奖寅界伏奴躇飘贬柄抹嘛闻变沏爆若璃炮煞祸右芬淮摊髓沥眺蜗牢ctmri在评缺血性心脏病中的作用ctmri在评缺血性心脏病中的作用microvascularobstructionafteramiismarkerofpoorprognosiswukc,circulation1998攒吠杖么南侨搽寿辐筛达啄昂俗缎互府睫糖情报硕苹剔揩甜寻咖呻逻王薄ctmri在评缺血性心脏病中的作用ctmri在评缺血性心脏病中的作用comprehensiveevaluation