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冠状动脉CT血管造影和5年心肌梗死风险
Coronary CT Angiography and 5-Year Risk of Myocardial Infarction


The SCOT-HEART Investigators* 心脑血管疾病 • 2018.09.06
相关阅读
• 比较计算机断层扫描血管造影与功能性压力测试在疑似冠心病中的应用 • 功能检查减少不必要的血管造影吗

冠脉CT血管造影使胸痛患者有显著获益

 

刘巍

首都医科大学附属北京安贞医院心内科

 

对于稳定型心绞痛患者的筛选及诊断,指南推荐先选择功能学检查,如运动负荷超声心动图、心肌核素检查。冠状动脉CT血管造影(CTA)往往作为其他检查结果不确定的情况下的替代选择。随着近年新研究的开展,CTA灵敏性高、特异性强的特点使其在稳定型心绞痛患者中可能有更高的价值。已发表的SCOT-HEART试验及PROMISE试验的短期随访结果(20~22个月)显示CTA较标准诊断并未能改善患者预后。然而,其远期效果如何?

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摘要


背景

虽然冠状动脉计算机断层扫描血管造影(CTA)提高了评估稳定型胸痛患者时的诊断确定性,但其对5年临床结局的影响尚不清楚。

 

方法

在一项开放标签、多中心、平行组试验中,我们将已被转诊至一家心脏病诊所,在此接受评估的4,146例稳定型胸痛患者随机分组,分别给予标准治疗+CTA(2,073例患者)或单独标准治疗(2,073例患者)。研究者在3~7年的随访期间评估了检查、治疗和临床结局。主要终点为5年时的冠心病所致死亡或非致死性心肌梗死。

 

结果

中位随访时间为4.8年,共进行了20,254患者-年的随访。CTA组中主要终点的5年发生率低于标准治疗组(2.3% [48例患者] vs. 3.9% [81例患者];风险比,0.59;95%置信区间[CI],0.41~0.84;P=0.004)。虽然在随访的前几个月中,CTA组侵入性冠状动脉造影和冠状动脉血运重建的发生率高于标准治疗组,但5年时的总发生率相似:CTA组491例患者和标准治疗组502例患者接受了侵入性冠状动脉造影(风险比,1.00;95% CI,0.88~1.13),CTA组279例患者和标准治疗组267例患者接受了冠状动脉血运重建(风险比,1.07;95% CI,0.91~1.27)。然而,CTA组启动了较多的预防性治疗(比值比,1.40;95% CI,1.19~1.65)和抗心绞痛治疗(比值比,1.27;95% CI,1.05~1.54)。心血管或非心血管死亡率或者任何原因所致死亡率无显著组间差异。

 

结论

在本试验的稳定型胸痛患者中,与单独标准治疗相比,标准治疗加用CTA显著降低了5年时的冠心病所致死亡或非致死性心肌梗死发生率,但未显著增加冠状动脉血管造影或冠状动脉血运重建的发生率(由苏格兰政府首席科学家办公室[Scottish Government Chief Scientist Office]等资助;SCOT-HEART在ClinicalTrials.gov注册号为NCT01149590)。





作者信息

The SCOT-HEART Investigators*
Address reprint requests to Dr. Newby at the University of Edinburgh, Rm. SU314, Chancellor’s Bldg., 49 Little France Crescent, Edinburgh EH16 4SA, United Kingdom, or at d.e.newby@ed.ac.uk. *A complete list of the SCOT-HEART Investigators is provided in the Supplementary Appendix, available at NEJM.org.

 

参考文献

1. Mark DB, Shaw L, Harrell FE Jr, et al. Prognostic value of a treadmill exercise score in outpatients with suspected coronary artery disease. N Engl J Med 1991;325:849-853.

2. 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.

3. Fleischmann KE, Hunink MG, Kuntz KM, Douglas PS. Exercise echocardiography or exercise SPECT imaging? A meta-analysis of diagnostic test performance. JAMA 1998;280:913-920.

4. Fihn SD, Blankenship JC, Alexander KP, et al. 2014 ACC/AHA/AATS/PCNA/SCAI/STS focused update of the guideline for the diagnosis and management of patients with stable ischemic heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines, and the American Association for Thoracic Surgery, Preventive Cardiovascular Nurses Association, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. J Am Coll Cardiol 2014;64:1929-1949.

5. 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: 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. Circulation 2012;126(25):e354-e471.

6. 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.

7. Miller JM, Rochitte CE, Dewey M, et al. Diagnostic performance of coronary angiography by 64-row CT. N Engl J Med 2008;359:2324-2336.

8. Mowatt G, Cummins E, Waugh N, et al. Systematic review of the clinical effectiveness and cost-effectiveness of 64-slice or higher computed tomography angiography as an alternative to invasive coronary angiography in the investigation of coronary artery disease. Health Technol Assess 2008;12:iii-iv, ix-143.

9. The SCOT-HEART Investigators. CT coronary angiography in patients with suspected angina due to coronary heart disease (SCOT-HEART): an open-label, parallel-group, multicentre trial. Lancet 2015;385:2383-2391.

10. Williams MC, Hunter A, Shah ASV, et al. Use of coronary computed tomographic angiography to guide management of patients with coronary disease. J Am Coll Cardiol 2016;67:1759-1768.

11. Douglas PS, Hoffmann U, Patel MR, et al. Outcomes of anatomical versus functional testing for coronary artery disease. N Engl J Med 2015;372:1291-1300.

12. Hoffmann U, Ferencik M, Udelson JE, et al. Prognostic value of noninvasive cardiovascular testing in patients with stable chest pain: insights from the PROMISE trial (Prospective Multicenter Imaging Study for Evaluation of Chest Pain). Circulation 2017;135:2320-2332.

13. Newby DE, Williams MC, Flapan AD, et al. Role of multidetector computed tomography in the diagnosis and management of patients attending the rapid access chest pain clinic, the Scottish Computed Tomography of the Heart (SCOT-HEART) trial: study protocol for randomized controlled trial. Trials 2012;13:184-184.

14. Woodward M, Brindle P, Tunstall-Pedoe H. Adding social deprivation and family history to cardiovascular risk assessment: the ASSIGN score from the Scottish Heart Health Extended Cohort (SHHEC). Heart 2007;93:172-176.

15. The West of Scotland Coronary Prevention Study Group. Computerised record linkage: compared with traditional patient follow-up methods in clinical trials and illustrated in a prospective epidemiological study. J Clin Epidemiol 1995;48:1441-1452.

16. Ford I, Murray H, Packard CJ, Shepherd J, Macfarlane PW, Cobbe SM. Long-term follow-up of the West of Scotland Coronary Prevention Study. N Engl J Med 2007;357:1477-1486.

17. Shah ASV, Anand A, Sandoval Y, et al. High-sensitivity cardiac troponin I at presentation in patients with suspected acute coronary syndrome: a cohort study. Lancet 2015;386:2481-2488.

18. National Institute for Health and Clinical Excellence. Chest pain of recent onset: assessment and diagnosis of recent onset chest pain or discomfort of suspected cardiac origin. Clinical Guideline 95. London: NICE, 2010.

19. National Institute for Health and Care Excellence. Chest pain of recent onset: assessment and diagnosis of recent onset chest pain or discomfort of suspected cardiac origin (update). Clinical Guideline 95. London: NICE, 2016.

20. Adamson PD, Hunter A, Williams MC, et al. Diagnostic and prognostic benefits of computed tomography coronary angiography using the 2016 National Institute for Health and Care Excellence guidance within a randomised trial. Heart 2018;104:207-214.

21. Ferencik M, Mayrhofer T, Bittner DO, et al. Use of high-risk coronary atherosclerotic plaque detection for risk stratification of patients with stable chest pain: a secondary analysis of the PROMISE randomized clinical trial. JAMA Cardiol 2018;3:144-152.

22. Cairns JA, Gent M, Singer J, et al. Aspirin, sulfinpyrazone, or both in unstable angina — results of a Canadian multicenter trial. N Engl J Med 1985;313:1369-1375.

23. Antiplatelet Trialists’ Collaboration. Collaborative overview of randomised trials of antiplatelet therapy — I: Prevention of death, myocardial infarction, and stroke by prolonged antiplatelet therapy in various categories of patients. BMJ 1994;308:81-106.

24. Fox KA, Poole-Wilson PA, Henderson RA, et al. Interventional versus conservative treatment for patients with unstable angina or non-ST-elevation myocardial infarction: the British Heart Foundation RITA 3 randomised trial. Lancet 2002;360:743-751.

25. Fanning JP, Nyong J, Scott IA, Aroney CN, Walters DL. Routine invasive strategies versus selective invasive strategies for unstable angina and non-ST elevation myocardial infarction in the stent era. Cochrane Database Syst Rev 2016;5:CD004815-CD004815.

26. Manson JE, Tosteson H, Ridker PM, et al. The primary prevention of myocardial infarction. N Engl J Med 1992;326:1406-1416.

27. Cholesterol Treatment Trialists’ (CTT) Collaboration. Efficacy and safety of more intensive lowering of LDL cholesterol: a meta-analysis of data from 170,000 participants in 26 randomised trials. Lancet 2010;376:1670-1681.

28. Gongora CA, Bavishi C, Uretsky S, Argulian E. Acute chest pain evaluation using coronary computed tomography angiography compared with standard of care: a meta-analysis of randomised clinical trials. Heart 2018;104:215-221.

29. Cheng VY, Berman DS, Rozanski A, et al. Performance of the traditional age, sex, and angina typicality-based approach for estimating pretest probability of angiographically significant coronary artery disease in patients undergoing coronary computed tomographic angiography: results from the multinational Coronary CT Angiography Evaluation for Clinical Outcomes: An International Multicenter Registry (CONFIRM). Circulation 2011;124:2423-2432.

30. Gandhi MM, Lampe FC, Wood DA. Incidence, clinical characteristics, and short-term prognosis of angina pectoris. Br Heart J 1995;73:193-198.

31. Daly CA, De Stavola B, Sendon JL, et al. Predicting prognosis in stable angina — results from the Euro heart survey of stable angina: prospective observational study. BMJ 2006;332:262-267.

32. Bonaca MP, Bhatt DL, Cohen M, et al. Long-term use of ticagrelor in patients with prior myocardial infarction. N Engl J Med 2015;372:1791-1800.

33. Sabatine MS, Giugliano RP, Keech AC, et al. Evolocumab and clinical outcomes in patients with cardiovascular disease. N Engl J Med 2017;376:1713-1722.

34. Ridker PM, Everett BM, Thuren T, et al. Antiinflammatory therapy with canakinumab for atherosclerotic disease. N Engl J Med 2017;377:1119-1131.

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