18F-FDG摄取量诊断非酒精性脂肪性肝病患者罹患冠状动脉粥样硬化性心脏病探讨.pdf

目的 探讨应用18F-FDG 摄取量诊断非酒精性脂肪性肝病(NAFLD)患者罹患冠状动脉粥样硬化性心脏病(CHD)的可行性。方法 2020 年 1 月 2021 年 12 月我院诊治的 NAFLD 患者 120 例,均接受冠状动脉 CT 血管成像(CCTA)和18F-氟代脱氧葡萄糖(FDG)正电子发射计算机断层显像(PET/CT)检查,绘制感兴趣区域(ROI),测量心脏标准摄取值【记录各层最大值(SUVmyo)】和肝脏 SUV(SUVliv),计算 SUVmyo/SUVliv 比值(SUVratio)。结果在 120 例NAFLD 患者中,经 CCTA 检查发现 CHD 患者 28 例;CHD 组体质指数、空腹血糖、总胆固醇和甘油三酯水平分别为(28.62.2)kg/m2、(6.92.1)mmol/L、(6.30.9)mmol/L 和(3.70.4)mmol/L,均显著高于 NAFLD 组【分别为(25.12.3)kg/m2、(5.21.5)mmol/L、(4.40.5)mmol/L 和(1.60.2)mmol/L,P0.05】,合并代谢综合征、高血压和糖尿病占比分别为28.6%、32.1%和 28.6%,均显著高于 NAFLD 组的 2.1%、10.8%和 4.3%(P0.05);CCTA 检查发现,CHD 组非钙化性斑块和非钙化斑块明显狭窄占比分别为28.6%和25.0%,均显著高于 NAFLD 组的4.3%和2.2%(P0.05);18F-FDG PET/CT 检查显示,CHD 组 SUVmyo 和 SUVratio 分别为(3.81.1)和(1.60.3),均显著低于 NAFLD 组【分别为(6.81.6)和(3.10.9),P0.05】。结论 采用 CCTA 和 PET/CT 检查可以帮助筛查 NAFLD 患者 CHD,其准确性还需与冠状动脉造影比较。【关键词】非酒精性脂肪性肝病;冠状动脉粥样硬化性心脏病;冠状动脉 CT 血管成像;18F-FDG 摄取量;诊断 DOI:10.3969/j.issn.1672-5069.2023.06.011 Diagnosis of coronary atherosclerotic heart disease in patients with nonalcoholic fatty liver disease by CCTA and18F-FDGintake Shao Xiaoru,Zhou Xiao,Ge Yingying.Department of Radiology,Fourth Affiliated Hospital,Nanjing Medical University,Nanjing 210000,Jiangsu Province,China【Abstract】ObjectiveThe aim of this study was to investigate the diagnosis of coronary atherosclerotic heart disease(CHD)in patients with nonalcoholic fatty liver disease(NAFLD)by coronary artery CT angiography(CCTA)and18F-FDGpositron emission computed tomography(PET/CT).Methods 120 patients with NAFLD were recruited in our hospital betweenJanuary 2020 and December 2021,and all underwent CCTA and PET/CT scan.The myocardial and liver standard uptake values(SUV)were obtained and recorded as SUVmyo,SUVliv and SUVmyo/SUVliv ratio(SUVratio).Results Out of the 120 patientswith NAFLD,the CCTA found CHD in 28 cases(23.3%);the body mass index,fasting blood glucose,total cholesterol andtriglyceride levels in patients with NAFLD and CHD were(28.62.2)kg/m2,(6.92.1)mmol/L,(6.30.9)mmol/L and(3.70.4)mmol/L,all significantly higher than(25.12.3)kg/m2,(5.21.5)mmol/L,(4.40.5)mmol/L and(1.60.2)mmol/L,P0.05,and the concomitant proportions of metabolic syndrome,hypertension and diabetes were 28.6%,32.1%and 28.6%,all much higher than 2.1%,10.8%and 4.3%(P0.05)in patients with NAFLD;the CCTA scan showed the non-calcifiedplaque and non-calcified plaque stenosis in coronary arteries in patients with CHD were 28.6%and 25.0%,both much higherthan 4.3%and 2.2%(P0.05)in patients with NAFLD;the18F-FDG PET/CT scan demonstrated that the SUVmyo and theSUVratio in patients with CHD were(3.81.1)and(1.60.3),both significantly lower than(6.81.6)and(3.10.9),respectively,P 0.05 in patients with NAFLD alone.Conclusion The screening of CHD in patients with NAFLD byCCTA and PET/CT scan is convenient and safe,which might beverified by coronary angiography.【Key words】Non-alcoholic fatty liver diseases;Coronary atheroscleroticheartdisease;18F-FDGintake;Coronary artery CT angiography;Diagnosis118实用肝脏病杂志 2023 年 11 月第 26 卷第 6 期 J Prac Hepatol,November.2023.Vol.26 No.6 随着社会经济的发展和人们生活方式的转变,非酒精性脂肪性肝病(nonalcoholic fatty liver disease,NAFLD)患病率不断上升。有研究显示,NAFLD 患者大多伴有糖脂代谢紊乱,脂肪沉积在 NAFLD 的发生发展过程中发挥重要作用1,2。在各种致病因素的作用下,NAFLD 病情进展可能导致血管内皮细胞功能出现障碍,致使脂质细胞、单核巨噬细胞等沉积在血管内皮下,最终形成动脉粥样斑块,导致心脑血管疾病的发生3。冠状动脉粥样硬化性心脏病(cor-onary atherosclerotic heart disease,CHD)是 导 致NAFLD 患者死亡的主要原因之一4。目前,临床常用冠状动脉 CT 血管成像(coronary computed tomo-graphy angiography,CCTA)和正电子发射计算机断层扫描成像(positron emission computed tomography,PET)等方法诊断动脉斑块形成,其中 PET/CT 可通过示踪剂18F-氟代脱氧葡萄糖(FDG)被 CHD 病变部位异常摄取实现检查目的,在心血管疾病的临床诊断方面应用较为广泛。本研究采用18F-FDG 摄取量诊断 NAFLD 患者罹患 CHD,分析了诊断效能,现报道如下。1 资料与方法1.1 一般资料 2020 年 1 月 2021 年 12 月我院诊治的 NAFLD 患者 120 例,男性 86 例,女性 34 例;年龄为 41 70 岁,平均年龄为(61.810.4)岁。符合非酒精性脂肪性肝病诊疗指南(2018 年修订版)5的标准,CHD 诊断以 CCTA 检查结果判定。纳入患者无饮酒史,无影像学检查禁忌证。排除标准:患有乙型肝炎或丙型肝炎;既往存在冠状动脉血管重建史;合并严重的肾功能障碍。1.2 临床指标记录患者年龄、体质指数、合并症(代谢综合征、高血压、糖尿病)。入院次日采集空腹静脉血,使用美国贝克曼库尔特有限公司生产的 AU-2700 型全自动生化分析仪检测血生化指标。1.3 CT 心脏冠脉成像检查使用美国 GE 公司生产的 Light Speed 64 排128 层螺旋 CT 扫描仪,管电压为120 kV,管电流为 100 450 mA,准直器为 64 mm2mm0.6 mm,厚度为0.75 mm,旋转时间为0.28 s。嘱患者平稳呼吸,经肘静脉注射造影剂优维显 60 mL,注射速率为 3.5 mL/s,行冠状动脉成像扫描。将扫描图像传输至专用工作站,由 2 名影像科医师进行影像评估。冠状动脉管腔狭窄程度 50%被诊断为CHD,冠状动脉斑块 CT 值 100 Hu 被定义为非钙化斑块,CT 值 130 Hu 则为钙化斑块,而 CT 值为101 129 Hu 为混合斑块。1.418F-FDG PET/CT 检查 使用美国 GE 公司生产的 Discovery PET/CT 扫描仪,禁食 6 h 以上。CT 扫描参数:管电压 120 kV,管电流 180 mA,准直器64 mm9 mm0.625 mm,厚度为 2.5 mm,旋转时间0.5 s。给予18F-FDG 5.18 MBq.kg-1静脉注射,静卧1 h。行三维模式 PET 扫描:视野 576 mm576 mm,矩阵 256256,层厚 5 mm,层间隔 5 mm。对 PET 数据经衰减校正、迭代重建,与 CT 图像一同传送至专用工作站,进行图像融合。分析冠状动脉图像钙化情况,测量心肌标准摄取值(standard uptake value,SUV)。在 心 脏 横 断 面 图 像 上 绘 制 感 兴 趣 区 域(region of interest,ROI),逐层测量心脏的 SUV,各层最大值记为 SUVmyo。沿肝脏右叶周边绘制 ROI,测量肝脏 SUV,测量 3 次,取平均值,记为 SUVliv,计算SUVmyo/SUVliv 比值(SUVratio)。1.5 统计学方法应用 SPSS 24.0 软件分析处理数据,P0.05 表示差异有统计学意义。计数资料的比较采用 x2检验,计量资料以(xs)表示,采用 t 检验。2 结果2.1 两组临床指标比较经影像学检查,在本组NAFLD 患者中发现 CHD 患者 28 例;NAFLD 合并CHD 组体质指数、空腹血糖、总胆固醇和甘油三酯水平均显著高于 NAFLD 组,合并代谢综合征、高血压和糖尿病占比均大于 NAFLD 组,差异有统计学意义(P0.05,表 1)。表 1 两组一般资料%,(xs)比较NAFLD(n=92)合并 CHD(n=28)年龄(岁)61.110.261.410.8体质指数(kg/m2)25.12.328.62.2代谢综合征2(2.1)8(28.6)高血压10(10.8)9(32.1)糖尿病4(4.3)8(28.6)空腹血糖(mmol/L)5.21.56.92.1总胆固醇(mmol/L)4.40.56.30.9甘油三酯(mmol/L)1.60.23.70.4 与 NAFLD 比,P0.052.2 两组 CCTA 检查结果比较CHD 组非钙化斑块和非钙化斑块明显狭窄占比均显著大于 NAFLD 组,差异有统计学意义(P0.05,表 2)。218实用肝脏病杂志 2023 年 11 月第 26 卷第 6 期 J Prac Hepatol,November.2023.Vol.26 No.6表 2 两组 CCTA 检查结果n(%)比较例数斑块类型钙化斑块混合斑块非钙化斑块狭窄程度钙化斑块狭窄混合斑块狭窄非钙化斑块狭窄CHD282(7.1)1(3.6)8(28.6)1(3.6)1(3.6)7(25.0)NAFLD926(6.5)2(2.2)4(4.3)2(2.2)3(3.3)2(2.2)与 NAFLD 比,P0.052.3 两组18F-FDG PET/CT 检测指标比较CHD 组SUVmyo 和 SUVratio 均显著低于 NAFLD 组,差异有统计学意义(P0.05,表 3)。表 3 两组18F-FDG PET/CT 检测指标(xs)比较例数SUVmyoSUVlivSUVratioCHD283.81.12.40.51.60.3NAFLD926.81.62.30.53.00.9 与 NAFLD 比,P55 岁人群非酒精性脂肪性肝病合并代谢综合征的现况分析.中华高血压杂志,2018,26(6):572-576.2Mansour-Ghanaei R,Mansour-Ghanaei F,Naghipour M,et al.Biochemical markers and lipid profile in nonalcoholic fatty liver dis-ease patients in the PERSIAN Guilan cohort study(PGCS),Iran.J Fam Med Prim 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