Abstract

Aims

To test the hypothesis that dobutamine stress echocardiography (DSE) reduces the rate of unnecessary invasive coronary angiography (CA) in patients with chronic stable coronary artery disease (CAD) and moderate to severe stenosis detected by coronary computed tomography angiography (CCTA).

Methods

This study included 49 consecutive, symptomatic CAD patients with coronary lesions greater than 50% detected by CCTA who underwent all DSE and a CA with pressure wire evaluation and FFR measurement. The DSE operators was aware of the CCTA results, but invasive physicians were blinded to DSE results. The primary endpoint was the negative predictive value of a CCTA followed by a DSE test for detecting significant coronary artery disease (CAD). This was defined by the presence of significant coronary lesions (>90% stenosis) or moderate coronary lesions (50–90%) with abnormal FFR value of less than 0.80 evaluated by invasive angiogram (CA). Secondary endpoints included major adverse cardiovascular events (MACEs).

Results

In patients with abnormal CCTA followed by CA, 33 patients (67.34%) had non-significant CAD lesions. In patients with both abnormal CCTA and DSE only 6 patients (12.24%) presented non-significant CAD. The negative predictive value of a CCTA followed by a DSE was significantly increased to 92.5%, when compared with CCTA alone. Thus DSE on top of abnormal CCTA could reduce unnecessary CA by 5.5 fold. During follow-up (mean 38.75 ± 12.25 months) 1 (2.1%) patient had a cardiac sudden death, 3 (6.12%) patients had an unplanned myocardial revascularization and 1 (2.1%) patient had a stroke, none of which occurred in patients with normal DSE. No patients experienced a myocardial infarction or needed un unplanned surgical revascularization.

Conclusions

The addition of DSE in case of abnormal CCTA increases significantly the negative predictive value for detecting significant CAD in need for revascularisation and thus reduces markedly the number of unnecessary CA. This diagnostic strategy has a higher diagnostic accuracy and negative predictive value to the opposite approach where an abnormal CCTA mandates a CA without additional functional testing.

中文翻译：

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冠状动脉计算机断层扫描血管造影检测到的中度冠状动脉疾病患者的多巴酚丁胺负荷超声心动图可降低不必要的冠状动脉造影率

摘要

宗旨

检验多巴酚丁胺负荷超声心动图 (DSE) 可降低慢性稳定型冠状动脉疾病 (CAD) 和冠状动脉计算机断层扫描血管造影 (CCTA) 检测到的中度至重度狭窄患者不必要的侵入性冠状动脉造影 (CA) 率的假设。

方法

这项研究包括 49 名连续的、有症状的 CAD 患者，其冠状动脉病变超过 50% 被 CCTA 检测到，他们接受了所有 DSE 和 CA，并进行了压力线评估和 FFR 测量。DSE 操作员知道 CCTA 结果，但侵入性医生对 DSE 结果视而不见。主要终点是 CCTA 的阴性预测值，然后进行 DSE 测试以检测显着冠状动脉疾病 (CAD)。这是通过有创血管造影 (CA) 评估的异常 FFR 值小于 0.80 的显着冠状动脉病变（>90% 狭窄）或中度冠状动脉病变 (50-90%) 的存在来定义的。次要终点包括主要不良心血管事件（MACE）。

结果

在 CCTA 异常后继发 CA 的患者中，33 名患者 (67.34%) 有不明显的 CAD 病变。在 CCTA 和 DSE 均异常的患者中，只有 6 名患者 (12.24%) 表现出非显着性 CAD。与单独使用 CCTA 相比，先进行 CCTA 后进行 DSE 的阴性预测值显着增加至 92.5%。因此，异常 CCTA 之上的 DSE 可以将不必要的 CA 减少 5.5 倍。在随访期间（平均 38.75 ± 12.25 个月），1 名 (2.1%) 患者发生心源性猝死，3 名 (6.12%) 患者进行计划外心肌血运重建，1 名 (2.1%) 患者发生中风，均未发生DSE正常的患者。没有患者发生心肌梗塞或需要计划外的手术血运重建。

结论

在异常 CCTA 的情况下添加 DSE 显着增加了检测需要血运重建的显着 CAD 的阴性预测值，从而显着减少了不必要的 CA 的数量。这种诊断策略与相反的方法相比具有更高的诊断准确性和负面预测价值，在相反的方法中，异常 CCTA 要求 CA 而无需额外的功能测试。