中心中心脏病学病学现状与状与进展展何作祥何作祥国家心血管病中心国家心血管病中心中国医学科学院阜外心血管病医院中国医学科学院阜外心血管病医院csnmcsnc.org20192019年北京年北京年北京年北京“ “五洲心血管病研五洲心血管病研五洲心血管病研五洲心血管病研讨讨讨讨会会会会Imaging in Coronary Artery DiseasenChanging rolesnCoronary stenosis (coronary angiography, CTA)?nmyocardial ischemia (SPECT, PET, stress echo) ?nChanging strategyAccuracy of Noninvasive Test for Diagnosis of CADNo. of No. of StudiesStudiesNo. of No. of PatientPatients sSensitivitSensitivity ySpecificitSpecificity yExercise ECGExercise ECG147147240472404768687777Exercise Exercise Perfusion Perfusion ImagingImaging2 2287512875189898080PharmacologicPharmacological Stress al Stress Scintigraphy Scintigraphy 11111000400400EBT Baseline Calcium ScoreEBT Baseline Calcium Score% with +SPECT% with +SPECT(n=17)(n=17)(n=37)(n=37)(n=93)(n=93)(n=89)(n=89)(n=10)(n=10)1-101-10246 patients all246 patients allasymptomaticasymptomaticexcept 34 withexcept 34 withatypical CPatypical CP58 + 10 years58 + 10 years75% with 2 or75% with 2 ormore RFmore RFHe et. al Circulation 2000;101:244-51He et. al Circulation 2000;101:244-51EBT Calcium Score and SPECT Thallium EBT Calcium Score and SPECT Thallium Stress TestingStress TestingClinical Characteristics (N=706) of Patients who Underwent CTA and SPECT14N (%)/averageN (%)/averageAgeAge56.19.956.19.9MaleMale450 (63.7%)450 (63.7%)Body Mass IndexBody Mass Index25.1*25.1*DiabetesDiabetes102 (14.4)102 (14.4)HypertensionHypertension388 (55.0)388 (55.0)HyperlipidemiaHyperlipidemia407 (57.6)407 (57.6)SmokingSmoking273 (38.7)273 (38.7)Family History of CADFamily History of CAD165 (23.4)165 (23.4)SymptomsSymptomsAsymptomaticAsymptomatic118 (16.7)118 (16.7)Atypical chest painAtypical chest pain476 (67.4)476 (67.4)Typical chest painTypical chest pain112 (15.9)112 (15.9)Accuracy of luminal stenosis by coronary CTA for detecting abnormal MPI15StenosisStenosisSensitivity*Sensitivity* Specificity*Specificity* PPV*PPV*NPV*NPV*Patients Patients LevelLevel50%50%80.280.256.756.721.521.595.195.175%75%48.448.490.490.442.742.792.292.290%90%29.729.798.498.4737390.490.4Vascular Vascular LevelLevel50%50%69.669.679.379.315.815.897.997.975%75%40.240.295.695.633.633.696.696.690%90%22.322.3999954.354.395.895.8CTA and SPECT/ CTA for Detection of Hemodynamically Significant Coronary LesionsRispler JACC 2019; 49: 1059-67050100PercentSens Spec PPV NPVSens Spec PPV NPVCTASPECT/ CTA9696999963953177PET/CT in CADNamdar M, et al. JNM 2019Myocardial Infarctions are causedby Low-Grade StenosesPooled data from 4 studies: Ambrose et al, 1988; Little et al, 1988; Nobuyoshi et al, 1991; and Giroud et al, 1992.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.)(Adapted from Falk et al.)Risk StratificationLow Low 1% per year 3% per year 3% per year Adapted from Gibbons RJ, et al. J Am Coll Cardiol. 2019;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 MarkersLeft ventricular systolic function Predictors of cardiac mortalityn nfactors estimating the extent of LV dysfunction n nLVEFn nthe extent of infarcted myocardiumn ntransient ischemic dilation of the LV n nand increased lung uptakePredictors of the subsequent development of acute ischemic syndromesn nmarkers of provocative ischemian nexertional symptoms,n nelectrocardiographic changesn nthe extent of reversible perfusion defectsn nstress-induced ventricular dyssynergyFollow-up Time (Months)9080706050403020100Cumulative Event-Free Survival1.0.9.8.7.6.5Normal CoronariesNormal CoronariesAngiographic CADAngiographic CADp=nsp=nsYang MF, NMC, 2019Prognostic value: Perfusion imaging vs. Angiographyn nPatients 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. 2019;97:535-543.Scan Result*Mildly AbnormalModerately AbnormalSeverely AbnormalNormal2946884455898Prognosis: MPI Scan Severity Predicts Outcome* P.001 *P.01nSSS13Cardiac Death Rate (%/y)Hachamovitch R, et al. Circulation 2019Enrollment and Outcomes3,071 Patients met protocol 3,071 Patients met protocol eligibility criteriaeligibility criteria2,287 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 dilated1,006 Received at least one stent784 Did not provide consent- 450 Did not receive MD approval- 237 Declined to give permission- 97 Had an unknown reason107 Were lost to follow-up1,149 Were included in the primary analysis1, Were assigned to medical-therapy group97 Were lost to follow-up1, Were included in the primary analysisShaw, L. J. et al. Circulation 2019;117:1283-1291Kaplan-Meier survival for patients by residual ischemia after 6 to 18 months of PCI+OMT or OMT心肌心肌SPECT正常与异常患者的冠正常与异常患者的冠状状动脉造影率脉造影率对比比N=105331Han PP, et al. Chin J Med 2019 (in press)心肌灌注心肌灌注显像正常与异常的冠状像正常与异常的冠状动脉再脉再血管化治血管化治疗比例比例N=105332P0.001Han PP, et al. Chin J Med 2019 (in press)ACCF/SCAI/STS/AATS/AHA/ASNC 2021 Appropriateness Criteria for Coronary Revascularizationn nThe use of coronary revascularization for patients with acute coronary syndromes and combinations of significant symptoms and/or ischemia was viewed favorably. n nRevascularization of asymptomatic patients or patients with low-risk findings on noninvasive testing and minimal medical therapy were viewed less favorably. Circulation. 2021;119:1330-2