提示: 手机请竖屏浏览!

磁共振灌注与血流储备分数指导冠心病治疗的比较
Magnetic Resonance Perfusion or Fractional Flow Reserve in Coronary Disease


Eike Nagel ... 心脑血管疾病 • 2019.06.20
相关阅读
• 血流储备分数指导下经皮冠状动脉介入治疗的5年结局 • 瞬时无波形比值或血流储备分数用于PCI的比较研究 • 什么是指导稳定型冠脉病变患者血运重建的最佳方法

摘要


背景

在稳定型心绞痛患者中,我们常采用两种策略来指导血运重建:一种涉及心肌灌注心血管磁共振成像(MRI),另一种涉及有创血管造影和血流储备分数(FFR)测定。目前尚不明确在心脏主要不良事件方面,基于心血管MRI的策略是否不劣于基于FFR的策略。

 

方法

我们开展了一项非盲法、多中心的临床有效性试验,将有≥2项心血管危险因素或者运动平板试验阳性的918例典型心绞痛患者随机分组,分别采用基于心血管MRI的策略或基于FFR的策略。对于缺血心肌达到至少6%的心血管MRI组患者或FFR≤0.8的FFR组患者,我们建议进行血运重建。复合主要结局包括1年内发生死亡、非致死性心肌梗死或靶血管血运重建。非劣效性界值为6个百分点的风险差异。

 

结果

心血管MRI组454例患者中的184例(40.5%)和FFR组464例患者中的213例(45.9%)符合建议进行血运重建的标准(P=0.11)。心血管MRI组接受初次血运重建的患者比FFR组少(162 [35.7%] vs. 209 [45.0%],P=0.005)。心血管MRI组421例患者中的15例(3.6%)和FFR组430例患者中的16例(3.7%)发生了主要结局(风险差异,-0.2个百分点;95%置信区间[CI],-2.7~2.4),这些结果达到了非劣效性阈值。两组12个月时无心绞痛的患者百分比无显著差异(心血管MRI组49.2%,FFR组43.8%,P=0.21)。

 

结论

在有冠心病危险因素的稳定型心绞痛患者中,心肌灌注心血管MRI组的冠状动脉血运重建发生率低于FFR组,并且心血管MRI在心脏主要不良事件方面不劣于FFR(由英国国家卫生研究院[National Institute for Health Research]盖伊和圣托马斯生物医学研究中心[Guy’s and St. Thomas’ Biomedical Research Centre]等资助;MR-INFORM在ClinicalTrials.gov注册号为NCT01236807)。





作者信息

Eike Nagel, M.D., John P. Greenwood, M.D., Gerry P. McCann, M.D., Nuno Bettencourt, M.D., Ajay M. Shah, M.D., Shazia T. Hussain, M.D., Divaka Perera, M.D., Sven Plein, M.D., Chiara Bucciarelli-Ducci, M.D., Matthias Paul, M.D., Mark A. Westwood, M.D., Michael Marber, M.D., Wolf-Stefan Richter, M.D., Valentina O. Puntmann, M.D., Carsten Schwenke, Ph.D., Jeanette Schulz-Menger, M.D., Rajiv Das, M.D., Joyce Wong, M.D., Derek J. Hausenloy, M.D., Henning Steen, M.D., and Colin Berry, M.D. for the MR-INFORM Investigators*
From the Institute for Experimental and Translational Cardiovascular Imaging, DZHK (German Center for Cardiovascular Research) Center for Cardiovascular Imaging, Goethe University, and the Department of Cardiology, University Hospital Frankfurt, Frankfurt am Main (E.N., V.O.P.), Pharmtrace (W.-S.R.), Schwenke Consulting (C.S.), and Charité–Universitätsmedizin Berlin, Freie Universität Berlin, Humboldt Universität zu Berlin, Berlin Institute of Health, DZHK, and Helios Kliniken Berlin-Buch (J.S.-M.), Berlin, and the Clinic for Cardiology, Angiology, and Pulmonology, University Hospital Heidelberg, Heidelberg (H.S.) — all in Germany; the Division of Biomedical Engineering and Imaging Sciences (E.N., S.T.H., S.P., M.P.) and British Heart Foundation Centre (A.M.S., D.P., M.M.), King’s College London, Barts Heart Centre, St. Bartholomew’s Hospital (M.A.W.), the Hatter Cardiovascular Institute, Institute of Cardiovascular Science, University College London (D.J.H.), and the National Institute for Health Research (NIHR) University College London Hospitals Biomedical Research Centre (D.J.H.), London, Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds (J.P.G., S.P.), the Department of Cardiovascular Sciences, University of Leicester and the NIHR Leicester Biomedical Research Centre, Glenfield Hospital (G.P.M.), and the Department of Cardiology, Glenfield Hospital (S.T.H.), Leicester, Bristol Heart Institute, University of Bristol and Bristol NIHR Biomedical Research Centre, Bristol (C.B.-D.), the Faculty of Health and Life Sciences, Northumbria University, and Freeman Hospital, Newcastle-upon-Tyne (R.D.), the Department of Cardiology, Royal Brompton and Harefield NHS Foundation Trust, Harefield Hospital, Uxbridge (J.W.), and the British Heart Foundation Glasgow Cardiovascular Research Centre, University of Glasgow, Glasgow (C.B.) — all in the United Kingdom; Cardiovascular Research and Development Unit, Faculty of Medicine, University of Porto, Porto, Portugal (N.B.); Kardiologie, Herzzentrum Luzern, Luzerner Kantonsspital, Lucerne, Switzerland (M.P.); and the Cardiovascular and Metabolic Disorders Program, Duke–National University of Singapore Medical School, and the National Heart Research Institute Singapore, National Heart Center, Yong Loo Lin School of Medicine, National University of Singapore, Singapore (D.J.H.). Address reprint requests to Dr. Nagel at Goethe University Frankfurt, Institute for Experimental and Translational Cardiovascular Imaging, Theodor-Stern-Kai 7, Frankfurt am Main 60590, Germany, or at eike.nagel@cardiac-imaging.org. *A complete list of the MR-INFORM Investigators is provided in the Supplementary Appendix, available at NEJM.org.

 

参考文献

1. Montalescot G, Sechtem U, Achenbach S, et al. 2013 ESC guidelines on the management of stable coronary artery disease: the Task Force on the management of stable coronary artery disease of the European Society of Cardiology. Eur Heart J 2013;34:2949-3003.

2. Fihn SD, Gardin JM, Abrams J, et al. 2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS guideline for the diagnosis and management of patients with stable ischemic heart disease: executive summary: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, and the American College of Physicians, American Association for Thoracic Surgery, Preventive Cardiovascular Nurses Association, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. J Am Coll Cardiol 2012;60:2564-2603.

3. Pijls NHJ, van Schaardenburgh P, Manoharan G, et al. Percutaneous coronary intervention of functionally nonsignificant stenosis: 5-year follow-up of the DEFER Study. J Am Coll Cardiol 2007;49:2105-2111.

4. Tonino PAL, De Bruyne B, Pijls NHJ, et al. Fractional flow reserve versus angiography for guiding percutaneous coronary intervention. N Engl J Med 2009;360:213-224.

5. Windecker S, Kolh P, Alfonso F, et al. 2014 ESC/EACTS guidelines on myocardial revascularization: the Task Force on Myocardial Revascularization of the European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS) developed with the special contribution of the European Association of Percutaneous Cardiovascular Interventions (EAPCI). Eur Heart J 2014;35:2541-2619.

6. Patel MR, White RD, Abbara S, et al. 2013 ACCF/ACR/ASE/ASNC/SCCT/SCMR appropriate utilization of cardiovascular imaging in heart failure: a joint report of the American College of Radiology Appropriateness Criteria Committee and the American College of Cardiology Foundation Appropriate Use Criteria Task Force. J Am Coll Cardiol 2013;61:2207-2231.

7. Greenwood JP, Maredia N, Younger JF, et al. Cardiovascular magnetic resonance and single-photon emission computed tomography for diagnosis of coronary heart disease (CE-MARC): a prospective trial. Lancet 2012;379:453-460.

8. Watkins S, McGeoch R, Lyne J, et al. Validation of magnetic resonance myocardial perfusion imaging with fractional flow reserve for the detection of significant coronary heart disease. Circulation 2009;120:2207-2213.

9. Takx RAP, Blomberg BA, El Aidi H, et al. Diagnostic accuracy of stress myocardial perfusion imaging compared to invasive coronary angiography with fractional flow reserve meta-analysis. Circ Cardiovasc Imaging 2015;8(1):e002666-e6.

10. Greenwood JP, Ripley DP, Berry C, et al. Effect of care guided by cardiovascular magnetic resonance, myocardial perfusion scintigraphy, or NICE guidelines on subsequent unnecessary angiography rates: the CE-MARC 2 randomized clinical trial. JAMA 2016;316:1051-1060.

11. Hussain ST, Paul M, Plein S, et al. Design and rationale of the MR-INFORM study: stress perfusion cardiovascular magnetic resonance imaging to guide the management of patients with stable coronary artery disease. J Cardiovasc Magn Reson 2012;14:65-65.

12. Diamond GA, Forrester JS. Analysis of probability as an aid in the clinical diagnosis of coronary-artery disease. N Engl J Med 1979;300:1350-1358.

13. Skinner JS, Smeeth L, Kendall JM, Adams PC, Timmis A. NICE guidance: chest pain of recent onset: assessment and diagnosis of recent onset chest pain or discomfort of suspected cardiac origin. Heart 2010;96:974-978.

14. Klocke FJ, Simonetti OP, Judd RM, et al. Limits of detection of regional differences in vasodilated flow in viable myocardium by first-pass magnetic resonance perfusion imaging. Circulation 2001;104:2412-2416.

15. Nagel E, Klein C, Paetsch I, et al. Magnetic resonance perfusion measurements for the noninvasive detection of coronary artery disease. Circulation 2003;108:432-437.

16. Giang TH, Nanz D, Coulden R, et al. Detection of coronary artery disease by magnetic resonance myocardial perfusion imaging with various contrast medium doses: first European multi-centre experience. Eur Heart J 2004;25:1657-1665.

17. Lockie T, Ishida M, Perera D, et al. High-resolution magnetic resonance myocardial perfusion imaging at 3.0-Tesla to detect hemodynamically significant coronary stenoses as determined by fractional flow reserve. J Am Coll Cardiol 2011;57:70-75.

18. Schwitter J, Wacker CM, van Rossum AC, et al. MR-IMPACT: comparison of perfusion-cardiac magnetic resonance with single-photon emission computed tomography for the detection of coronary artery disease in a multicentre, multivendor, randomized trial. Eur Heart J 2008;29:480-489.

19. Boden WE, O’Rourke RA, Teo KK, et al. Optimal medical therapy with or without PCI for stable coronary disease. N Engl J Med 2007;356:1503-1516.

20. De Bruyne B, Pijls NHJ, Kalesan B, et al. Fractional flow reserve-guided PCI versus medical therapy in stable coronary disease. N Engl J Med 2012;367:991-1001.

21. Al-Lamee R, Thompson D, Dehbi HM, et al. Percutaneous coronary intervention in stable angina (ORBITA): a double-blind, randomised controlled trial. Lancet 2018;391:31-40.

22. Shaw LJ, Berman DS, Picard MH, et al. Comparative definitions for moderate-severe ischemia in stress nuclear, echocardiography, and magnetic resonance imaging. JACC Cardiovasc Imaging 2014;7:593-604.

服务条款 | 隐私政策 | 联系我们