Perfuziona scintigrafija miokarda u predikciji postojanja hemodinamski značajnih stenoza koronarnih arterija
Nuklearno medicinska predikcija hemodinamske signifikantnosti stenoze koronarne arterije
Ključne reči:
Perfuziona scintigrafija miokarda, Koronarna bolest, Hemodinamika stenoze koronarne arterije, Anatomska signifikantnost koronarne stenoze.
Sažetak
Uvod/Cilj. Anatomski nesignifikantna stenoza koronarnih arterija dobijena na koronarnoj angiografiji, može biti hemodinamski signifikantna i kao takva izazvati ishemijske promene miokarda. Cilj rada je bio da se proceni dijagnostička tačnost perfuzione scintigrafije miokarda (SPECT MPI) u detekciji hemodinamski značajne stenoze koronarnih arterija kod pacijenata sa umerenim rizikom od ishemije, bez prethodno otkrivene koronarne bolesti.
Pacijenti i metodologija. Istraživanjem je obuhvaćeno 258 pacijenata. 54% žena i 46% muškaraca sa prosečnom starošću od 59,0 ± 10,1 godina. SPECT MPI je urađen dvodnevnim protokolom sa 99mTc-MIBI. Patološkim nalazom smatrno je postojanje perfuzionih defekata. Test fizičkog opterećenja je urađen po Bruceovom protokolu. Koronarna angiografija (CA) je urađena po standardnom protokolu. Anatomski značajnim suženjem koronarne arterije smatrala se stenoza >70%. Stenoze od 30% do 69% su smatrane hemodinamski značajnim kod pacijenata sa reverzibilnim defektima perfuzije na SPECT MPI.
Rezultati. Osetljivost (SE) SPECT MPI je bila 89%, specifičnost (SP) 42%, pozitivna prediktivna vrednost (PPV) 86%, negativna prediktivna vrednost (NPV) 50%, a ukupna dijagnostička tačnost (ACC) 74% kada su rezultati upoređeni sa stenozom >70%. Uključivanjem stenoze od 30% do 69% dobijene vrednosti dijagnostičkih pokazatelja pouzdanosti SPECT MPI su: SE 91%; SP 100%; PPV 100%; NPV 50% i ACC 91%.
Zaključak. Samo sa CA nije moguće dokazati postojanje hemodinamskog značaja stenoza koronarnih arterija od 30% do 69%, što predstavlja regrutnu oblast za razvoj ishemije. SPECT MPI pokazuje visoke SE, SP, PPV i ACC u otkrivanju postojanja poremećaja perfuzije miokarda leve komore sa stenozama koronarnih arterija sa ili bez anatomski značajne vrednosti.
Reference
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https://doi.org/10.1016/S0735-1097(00)01054-8
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https://doi.org/10.1161/01.CIR.0000118498.35499.B2
20. Montalescot G, Sechtem U, Achenbach S, Andreotti F, Arden C, Budaj A, et al. 2013 ESC guidelines on the management of stable coronary artery disease. Eur Heart J 2013;34:2949.
https://doi.org/10.1093/eurheartj/eht296
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https://doi.org/10.1016/j.atherosclerosis.2013.06.008
22. Diamond GA, Forester JS. Analysis of probability as an aid in the clinical diagnosis of coronary artery disease. NEJM 1979;300:1350-1358.
https://doi.org/10.1056/NEJM197906143002402
23. Pepine CJ, Balaban RS, Bonow RO, Diamond GA, Johnson BD, Johnson PA, et al. Women's Ischemic Syndrome Evaluation: current status and future research directions: report of the National Heart, Lung, and Blood Institute workshop: October 2-4, 2002: Section 1: diagnosis of stable ischemia and ischemic heart disease. Circulation 2004;109:44-46.
https://doi.org/10.1161/01.CIR.0000116206.77324.5B
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https://doi.org/10.1001/jama.293.4.477
25. Cohen-Solal A, Zannad F, Kayanakis JG, Gueret P, Aupetit JF, Kolsky H. Multicentre study of the determination of peak oxygen uptake and ventilatory threshold during bicycle exercise in chronic heart failure: comparison of graphical methods, interobserver variability and influence of the exercise protocol: the VO2 French Study Group. Eur Heart J 1991;12:1055-1063.
https://doi.org/10.1093/oxfordjournals.eurheartj.a059837
26. Douglas PS. Is noninvasive testing for coronary artery disease accurate? Circulation 1997;95:299 -302.
https://doi.org/10.1161/01.CIR.95.2.299
27. 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.
https://doi.org/10.1001/jama.280.10.913
28. Karvonen MJ, Kental E, Mustala O. The effects of training on heart rate a longitudinal study. Ann Med Exp Fenn 1957;35:307-315.
https://doi.org/10.1002/j.2164-4918.1957.tb01772.x
29. Melin JA, Wijns W, Vanbutsele RJ, Robert A, De Coster P, Brasseur LA, et al. Alternative diagnostic strategies for coronary artery disease in women: demonstration of the usefulness and efficiency of probability analysis. Circulation 1985;71:535-542.
https://doi.org/10.1161/01.CIR.71.3.535
30. Gutterman DD. Silent myocardial ischemia. Circ J 2009;73:785-797.
https://doi.org/10.1253/circj.CJ-08-1209
31. Stramba-Badiale M, Bonazzi O, Casadei G, Dal Palù C, Magnani B, Zanchetti A. Prevalence of episodes of ST-segment depression among mild-to-moderate hypertensive patients in northern Italy: the Cardioscreening Study. J Hypertens 1998;16:681-688.
https://doi.org/10.1097/00004872-199816050-00016
32. Levine GN, Bates ER, Blankenship JC, Bailey SR, Bittl JA, Cercek B, et al. 2011 ACCF/AHA/ SCAI guideline for percutaneous coronary intervention: a report of the American college of Cardiology Foundation/American Heart Association Task Force on practice guidelines and the society for cardiovascular angiography and interventions. J Am Coll Cardiol 2011;58:44 -122.
https://doi.org/10.1016/j.jacc.2011.08.007
33. Leape LL, Park RE, Bashore TM, Harrison JK, Davidson CJ, Brook RH. Effect of variability in the interpretation of coronary angiograms on the appropriateness of use of coronary revascularization procedures. Am Heart J 2000;139:106-113.
https://doi.org/10.1016/S0002-8703(00)90316-8
34. Nakazato R, Shalev A, Doh JH, Koo BK, Gransar H, Gomez MJ Aggregate plaque volume by coronary computed tomography angiography is superior and incremental to luminal narrowing for diagnosis of ischemic lesions of intermediate stenosis severity. J Am Coll Cardiol 2013;62:460-467.
https://doi.org/10.1016/j.jacc.2013.04.062
35. Ambrose JA, Tannenbaum MA, Alexopoulos D, et al. Angiographic progression of coronary artery disease and the development of myocardial infarction. J Am Coll Cardiol 1988;12:56-62.
https://doi.org/10.1016/0735-1097(88)90356-7
36. Patel MR, Peterson ED, Dai D, Brennan JM, Redberg RF, Anderson HV, Brindis RG, Douglas PS. Low diagnostic yield of elective coronary angiography. N Engl J Med 2010;362:886-895.
https://doi.org/10.1056/NEJMoa0907272
https://doi.org/10.7150/ijms.9623
2. Crossman DC. The pathophysiology of myocardial ischemia. Heart 2004;90:576-580.
https://doi.org/10.1136/hrt.2003.029017
3. Dangas G, Mintz GS, Mehran R, Lansky AJ, Kornowski R, Pichard AD, et al., Preintervention arterial remodeling as an independent predictor of target lesion revascularization after non-stent coronary intervention. An analysis of 777 lesions with intravascular ultrasound imaging. Circulation 1999;99:3149-3154.
https://doi.org/10.1161/01.CIR.99.24.3149
4. Scanlon PJ, Faxon DP, Audet AM, Carabello B, Dehmer GJ, Eagle KA, et al. ACC/AHA guidelines for coronary angiography: a report of the American college of Cardiology/ American Heart Association Task Force on practice guidelines (Committee on coronary angiography). J Am Coll Cardiol 1999;33:1756-1824.
https://doi.org/10.1016/S0735-1097(99)00126-6
5. Braunwald E, Antman EM, Beasley JW, Califf RM, Cheitlin MD, Hochman JS, et al. ACC/AHA Guideline update for the management of patients with unstable angina and non-ST segment myocardial infarction - Summary article: J Am Coll Cardiol 2002;40:1366-1374.
https://doi.org/10.1016/S0735-1097(02)02336-7
6. Fihn SD, Gardin JM, Abrams J, Berra K, Blankenship JC, Dallas AP, et al. 2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS guideline for the diagnosis and management of patients with stable ischemic heart disease. J Am Coll Cardiol; 2012;60:44-164.
https://doi.org/10.1016/j.jacc.2012.07.013
7. Hesse B, Tägil K, Cuocolo A, Anagnostopoulos A, Bardiés M, Bax J, et al. EANM/ESC procedural guidelines for myocardial perfusion imaging in nuclear cardiology. Eur J Nucl Med Mol Imaging 2005;32:855-897.
https://doi.org/10.1007/s00259-005-1779-y
8. Kula M, Tutuş A, Unal S, Topsakal R, Ergin A Technetium-99m-tetrofosmin imaging with incremental nitroglycerin infusion to detect severely ischaemic but viable myocardium: a comparative study with thallium-201. Nucl Med Commun 2003;24:987-994.
https://doi.org/10.1097/00006231-200309000-00007
9. Niyaz K, Niaz K, Zaman MU, Kamal S, Usmani S, Habib S, Hashmi H, Husssain SW. Assessment of viable myocardium by nitrate augmented 99mTc MIBI myocardial perfusion imaging. J Pak Med Assoc 2007;57:83-87.
10. Bruce AR, Lovejoy FW Jr., Pearson R, Paul N. Yu G, Brothers G, et al. Normal respiratory and circulatory pathways of adaptation in exercise. J Clin Invest 1949;28: 1423-1430.
https://doi.org/10.1172/JCI102207
11. Bruce AR, Lovejoy FW Jr., Pearson R, Paul N. Yu G, Brothers G, et al. Variability of respiratory and circulatory performance during standardized exercise. J Clin Invest 1949; 28:1431-1438.
https://doi.org/10.1172/JCI102208
12. Cohn JN, ed. Quantitative exercise testing for the cardiac patient: the value of monitoring gas exchange: introduction. Circulation 1987;76:1-58.
13. Londeree BR, Moeschberger ML. Influence of age and other factors on maximal heart rate. J Cardiac Rehabil 1984;4:44-49.
14. Tanaka H, Monahan KD, Seals DR. Age-predicted maximal heart rate revisited. J Am Coll Cardiol 2001;37:153-156.
https://doi.org/10.1016/S0735-1097(00)01054-8
15. Spellberg RD, Ungar I. The Percutaneous Femoral Artery Approach to Selective Coronary Arteriography. Circulation 1967;36:730-733.
https://doi.org/10.1161/01.CIR.36.5.730
16. Levine GN, Bates ER, Blankenship JC, Bailey SR, Bittl JA, Cercek B, et al. 2011 ACCF/AHA/ SCAI guideline for percutaneous coronary intervention: a report of the American college of Cardiology Foundation/American Heart Association Task Force on practice guidelines and the society for cardiovascular angiography and interventions. J Am Coll Cardiol 2011;58:44 -122.
https://doi.org/10.1016/j.jacc.2011.08.007
17. Klocke FJ, Baird MG, Lorell BH, Bateman TM, Messer JV, Berman DS, et al. ACC/AHA/ASNC guidelines for the clinical use of cardiac radionuclide imaging- executive summary: a report of the American college of Cardiology/American Heart Association Task Force on practice guidelines (ACC/AHA/ASNC Committee to revise the 1995 guidelines for the clinical use of cardiac radionuclide imaging). Circulation 2003;108:1404-1418.
https://doi.org/10.1161/01.CIR.0000080946.42225.4D
18. Shaw LJ, Hachamovitch R, Peterson ED, Lewin HC, Iskandrian AE, Miller DD, et al. Using an outcomes-based approach to identify candidates for risk stratification after exercise treadmill testing. J Gen Intern Med 1999;14:1-9.
https://doi.org/10.1046/j.1525-1497.1999.00273.x
19. Unal B, Critchley JA, Capewell S. Explaining the decline in coronary heart disease mortality in England and Wales between 1981 and 2000. Circulation 2004;109:1101-1107.
https://doi.org/10.1161/01.CIR.0000118498.35499.B2
20. Montalescot G, Sechtem U, Achenbach S, Andreotti F, Arden C, Budaj A, et al. 2013 ESC guidelines on the management of stable coronary artery disease. Eur Heart J 2013;34:2949.
https://doi.org/10.1093/eurheartj/eht296
21. Nakanishi R, Rana JS, Rozanski A, Cheng VY, Gransar H, Thomson LE, Miranda-Peats R, et al. Relationship of dyspnea vs. typical angina to coronary artery disease severity, burden, composition and location on coronary CT angiography. Atherosclerosis. 2013;230:61-66.
https://doi.org/10.1016/j.atherosclerosis.2013.06.008
22. Diamond GA, Forester JS. Analysis of probability as an aid in the clinical diagnosis of coronary artery disease. NEJM 1979;300:1350-1358.
https://doi.org/10.1056/NEJM197906143002402
23. Pepine CJ, Balaban RS, Bonow RO, Diamond GA, Johnson BD, Johnson PA, et al. Women's Ischemic Syndrome Evaluation: current status and future research directions: report of the National Heart, Lung, and Blood Institute workshop: October 2-4, 2002: Section 1: diagnosis of stable ischemia and ischemic heart disease. Circulation 2004;109:44-46.
https://doi.org/10.1161/01.CIR.0000116206.77324.5B
24. Bugiardini R, Bairey Merz CN. Angina with "normal" coronary arteries: a changing philosophy. JAMA 2005;293:477-484.
https://doi.org/10.1001/jama.293.4.477
25. Cohen-Solal A, Zannad F, Kayanakis JG, Gueret P, Aupetit JF, Kolsky H. Multicentre study of the determination of peak oxygen uptake and ventilatory threshold during bicycle exercise in chronic heart failure: comparison of graphical methods, interobserver variability and influence of the exercise protocol: the VO2 French Study Group. Eur Heart J 1991;12:1055-1063.
https://doi.org/10.1093/oxfordjournals.eurheartj.a059837
26. Douglas PS. Is noninvasive testing for coronary artery disease accurate? Circulation 1997;95:299 -302.
https://doi.org/10.1161/01.CIR.95.2.299
27. 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.
https://doi.org/10.1001/jama.280.10.913
28. Karvonen MJ, Kental E, Mustala O. The effects of training on heart rate a longitudinal study. Ann Med Exp Fenn 1957;35:307-315.
https://doi.org/10.1002/j.2164-4918.1957.tb01772.x
29. Melin JA, Wijns W, Vanbutsele RJ, Robert A, De Coster P, Brasseur LA, et al. Alternative diagnostic strategies for coronary artery disease in women: demonstration of the usefulness and efficiency of probability analysis. Circulation 1985;71:535-542.
https://doi.org/10.1161/01.CIR.71.3.535
30. Gutterman DD. Silent myocardial ischemia. Circ J 2009;73:785-797.
https://doi.org/10.1253/circj.CJ-08-1209
31. Stramba-Badiale M, Bonazzi O, Casadei G, Dal Palù C, Magnani B, Zanchetti A. Prevalence of episodes of ST-segment depression among mild-to-moderate hypertensive patients in northern Italy: the Cardioscreening Study. J Hypertens 1998;16:681-688.
https://doi.org/10.1097/00004872-199816050-00016
32. Levine GN, Bates ER, Blankenship JC, Bailey SR, Bittl JA, Cercek B, et al. 2011 ACCF/AHA/ SCAI guideline for percutaneous coronary intervention: a report of the American college of Cardiology Foundation/American Heart Association Task Force on practice guidelines and the society for cardiovascular angiography and interventions. J Am Coll Cardiol 2011;58:44 -122.
https://doi.org/10.1016/j.jacc.2011.08.007
33. Leape LL, Park RE, Bashore TM, Harrison JK, Davidson CJ, Brook RH. Effect of variability in the interpretation of coronary angiograms on the appropriateness of use of coronary revascularization procedures. Am Heart J 2000;139:106-113.
https://doi.org/10.1016/S0002-8703(00)90316-8
34. Nakazato R, Shalev A, Doh JH, Koo BK, Gransar H, Gomez MJ Aggregate plaque volume by coronary computed tomography angiography is superior and incremental to luminal narrowing for diagnosis of ischemic lesions of intermediate stenosis severity. J Am Coll Cardiol 2013;62:460-467.
https://doi.org/10.1016/j.jacc.2013.04.062
35. Ambrose JA, Tannenbaum MA, Alexopoulos D, et al. Angiographic progression of coronary artery disease and the development of myocardial infarction. J Am Coll Cardiol 1988;12:56-62.
https://doi.org/10.1016/0735-1097(88)90356-7
36. Patel MR, Peterson ED, Dai D, Brennan JM, Redberg RF, Anderson HV, Brindis RG, Douglas PS. Low diagnostic yield of elective coronary angiography. N Engl J Med 2010;362:886-895.
https://doi.org/10.1056/NEJMoa0907272
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2025/12/09
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Originalni rad / Original article