五洲会-何作祥-核心脏病学现状与进展A课件.ppt

,*,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,*,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 roles,Coronary stenosis(coronary angiography,CTA)?,myocardial ischemia(SPECT,PET,stress echo)?,Changing strategy,Accuracy of Noninvasive Test for Diagnosis of CAD,No.of Studies,No.of Patients,Sensitivity,Specificity,Exercise ECG,147,24047,68,77,Exercise Perfusion Imaging,2,28751,89,80,Pharmacological Stress Scintigraphy,11,400,EBT Baseline Calcium Score,%with+SPECT,(n=17),(n=37),(n=93),(n=89),(n=10),1-10,246 patients all,asymptomatic,except 34 with,atypical CP,58,+,10 years,75%with 2 or,more 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,N(%)/average,Age,56.19.9,Male,450(63.7%),Body Mass Index,25.1*,Diabetes,102(14.4),Hypertension,388(55.0),Hyperlipidemia,407(57.6),Smoking,273(38.7),Family History of CAD,165(23.4),Symptoms,Asymptomatic,118(16.7),Atypical chest pain,476(67.4),Typical chest pain,112(15.9),Accuracy of luminal stenosis by coronary CTA for detecting abnormal MPI,15,Stenosis,Sensitivity*,Specificity*,PPV*,NPV*,Patients Level,50%,80.2,56.7,21.5,95.1,75%,48.4,90.4,42.7,92.2,90%,29.7,98.4,73,90.4,Vascular Level,50%,69.6,79.3,15.8,97.9,75%,40.2,95.6,33.6,96.6,90%,22.3,99,54.3,95.8,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,LVEF,the extent of infarcted myocardium,transient ischemic dilation of the LV,and increased lung uptake,Predictors of the subsequent,development of acute,ischemic syndromes,markers of provocative ischemia,exertional symptoms,electrocardiographic changes,the extent of reversible perfusion defects,stress-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 dilated,1,006 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,symptoms and/or,ischemia,was viewed favorably.,Revascularization of asymptomatic patients or patients with,low-risk findings on,noninvasive testing,and minimal medical,therapy were viewed less favorably.,Circulation.2009;119:1330-1352,