64排螺旋CT在老年冠心病合并糖尿病诊断中的应用研究
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摘要
[研究背景及意义]冠心病、糖尿病均是严重危害人类健康的临床多发病、常见病,糖尿病也被视为冠心病等危症,冠心病合并糖尿病患者的动脉粥样硬化更严重、冠状动脉病变范围也更广泛,老年患者尤甚。目前,选择性冠状动脉造影依然是诊断冠心病的“金标准”,因为它可以直接判断血管腔狭窄程度,在冠心病的诊断上具有独特的优势,但是它具有一定的创伤性和危险性,并且费用高,评价冠状动脉病变也存在缺陷。有文献报道,1995年欧洲约有100万例患者行选择性冠状动脉造影,其中冠状动脉正常或其病变不适于介入治疗的患者占72%。而临床上大多数患者,尤其是老年患者,对诊断手段的需求是无创、准确和安全。近年随着多排CT在临床上的广泛应用及CT技术的飞速发展与进步,尤其是64排螺旋CT,因其扫描速度快,结合心电门控技术和先进的图像处理技术,基本排除了心脏搏动和呼吸产生的影响,具有较高的时间和空间分辨力,判断病变有较高的敏感性和特异性,且相对无创、价廉、方便和极低的风险性；而这些是选择性冠状动脉造影、心脏超声、运动平板试验、动态心电图等检查手段所不能兼备的。64排螺旋CT在老年冠心病合并糖尿病中的临床应用也日益为医学界关注。
[目的]通过64排螺旋CT检查老年冠心病合并糖尿病患者冠脉病变程度及冠脉内病变性质,探讨其在此类患者中的应用价值及其局限性。
[方法]52例临床诊断为老年冠心病合并糖尿病的患者,均行冠状动脉64排螺旋CT血管造影及选择性冠状动脉造影检查。对所有增强扫描轴位图像进行多平面重建(multiplanar reconstuction,MPR)、容积再现(volume rendering,VR)、最大密度投影(maximum intensity projection,MIP)、曲面重建(curved planar reconstuction,CPR)、仿真血管内镜(vitual endoscopy,VE)等后处理,评估所有冠脉管腔狭窄程度及斑块性质。入选所有患者均在两周内进行了选择性冠状动脉造影,根据造影结果来判断MSCT对老年冠心病合并糖尿病的冠状动脉病变的预测价值。
[结果]
1.52例患者常规冠脉造影在所有患者共实际分析676个冠脉节段,其中发现174个节段有≥50%狭窄,52例患者只有4例为轻度病变,其余均为中重度病变；其中闭塞性病变11个,占6.3%;长病变26个,占14.9%；单支病变的患者占19.2%(10/52),双支病变占38.5%(20/52),三支病变占42.3%(22/52)。在常规冠状动脉造影发现的174个节段有≥50%狭窄的节段中,CT冠状动脉成像正确检出了155个。64排螺旋CT冠状动脉成像诊断冠状动脉狭窄的敏感性为89.1%(155/174),特异性为92.8%(466/502),准确率91.9%(621/676),阳性预测值81.2%(155/191),阴性预测值96.1%(466/485)。
2.合并糖尿病老年冠心病患者冠状动脉粥样硬化斑块以软斑块和混合斑块多见,部分合并钙化,单纯钙化斑块较少。
[结论]
1.64排螺旋CT冠状动脉成像可清晰显示冠状动脉主干及其诸主要分支,对冠状动脉狭窄有较高的诊断价值。
2.合并糖尿病的老年冠心病患者多支血管病变的发生率高,冠状动脉粥样硬化斑块以软斑块和混合斑块多见,部分合并钙化；闭塞性病变及长病变多见。
3.64排螺旋CT虽然由于受运动、钙化等影响,有一定比例的血管不能准确评估,但可以作为合并糖尿病的老年冠心病患者危险分层,判断预后,指导治疗,进行二级预防的一种有效的检查手段。
Background:Coronary Heart Disease(CHD) is one of the most common diseases that threaten people's life. Diabetes Mellitus(DM) as a CHD risk equivalent promote the progress of atherosclerosis. It is proved that patient with both CHD and DM more common have multivessel atherosclerosis. Invasive coronary angiography is considered the gold standard for diagnosis of CHD. The noninvasive multislice computed tomography coronary angiography is an almost established coronary imaging technique improving day by day.64-Detector computed tomography angiography in diagnosis and assessment of coronary artery disease-especially for old people with both CHD and DM-is increasingly attentioned.
Objectives:The aim of this study was to investigate the accuracy of 64-slice computed tomography coronary angiography for assessing quality and severity of coronary stenoses in comparison with invasive coronary angiography.
Methods:Fifty-two eldly patients with both CHD and DM, in whom the coronary tree was first studied by 64-detector computed tomography angiography and afterwards, by invasive coronary angiography, were enrolled in the study. All the enhanced scan axial images were processed by multiplanar reconstruction (MPR), volume rendering (VR), maximum intensity projection (MIP), curved planar reconstruction(CPR), vitual endoscopy(VE), and so on. After post-processing, quality and severity of significant coronary stenoses will be assessed. All the patient were accepted invasive coronary angiography in two weeks after being given 64-detector computed tomography angiography. The sensitivity, specificity, predictive positive value and negative predictive value were determined in order to validate the diagnostic accuracy of multislice computed tomography for detection of coronary lesions compared with invasive coronary angiography.
Results:In the fifty-two patients,676 coronary artery segments were assessed, 174 coronary artery segments were detected more than 50% diameter stenosis lesion by invasive coronary angiography, the lesions in 4 patients were minimal stenosis, the rest lesions were severe coronary narrow lesions; the occlusive disease have 11 segments, taking 6.3%; long diasease have 26 segments, taking 14.9%; single-vessel disease taking 19.2%(10/52), two-vessel disease taking 38.5%(20/52), three--vessel disease taking 42.3%(22/52). In 174 coronary artery segments detect more than 50% diameter stenosis lesion by invasive coronary angiography, computed tomography angiography checked out 155 coronary artery segments accurately.The sensitivity, specificity, positive predictive value, and negative predictive value were 89.1%,92.8%,81.2%, and 96.1% respectively per segment. The diagnostic accuracy in patients were very high(91.9%).
Conclusions:64-detector computed tomography coronary angiography can clearly display the left main and the the main branches. Patients with DM more often have multivessel disease and serious lesions.64-detector computed tomography coronary angiography has a very good diagnostic accuracy in our study.
[目的]通过64排螺旋CT检查老年冠心病合并糖尿病患者冠脉病变程度及冠脉内病变性质,探讨其在此类患者中的应用价值及其局限性。
[方法]52例临床诊断为老年冠心病合并糖尿病的患者,均行冠状动脉64排螺旋CT血管造影及选择性冠状动脉造影检查。对所有增强扫描轴位图像进行多平面重建(multiplanar reconstuction,MPR)、容积再现(volume rendering,VR)、最大密度投影(maximum intensity projection,MIP)、曲面重建(curved planar reconstuction,CPR)、仿真血管内镜(vitual endoscopy,VE)等后处理,评估所有冠脉管腔狭窄程度及斑块性质。入选所有患者均在两周内进行了选择性冠状动脉造影,根据造影结果来判断MSCT对老年冠心病合并糖尿病的冠状动脉病变的预测价值。
[结果]
1.52例患者常规冠脉造影在所有患者共实际分析676个冠脉节段,其中发现174个节段有≥50%狭窄,52例患者只有4例为轻度病变,其余均为中重度病变；其中闭塞性病变11个,占6.3%;长病变26个,占14.9%；单支病变的患者占19.2%(10/52),双支病变占38.5%(20/52),三支病变占42.3%(22/52)。在常规冠状动脉造影发现的174个节段有≥50%狭窄的节段中,CT冠状动脉成像正确检出了155个。64排螺旋CT冠状动脉成像诊断冠状动脉狭窄的敏感性为89.1%(155/174),特异性为92.8%(466/502),准确率91.9%(621/676),阳性预测值81.2%(155/191),阴性预测值96.1%(466/485)。
2.合并糖尿病老年冠心病患者冠状动脉粥样硬化斑块以软斑块和混合斑块多见,部分合并钙化,单纯钙化斑块较少。
[结论]
1.64排螺旋CT冠状动脉成像可清晰显示冠状动脉主干及其诸主要分支,对冠状动脉狭窄有较高的诊断价值。
2.合并糖尿病的老年冠心病患者多支血管病变的发生率高,冠状动脉粥样硬化斑块以软斑块和混合斑块多见,部分合并钙化；闭塞性病变及长病变多见。
3.64排螺旋CT虽然由于受运动、钙化等影响,有一定比例的血管不能准确评估,但可以作为合并糖尿病的老年冠心病患者危险分层,判断预后,指导治疗,进行二级预防的一种有效的检查手段。
Background:Coronary Heart Disease(CHD) is one of the most common diseases that threaten people's life. Diabetes Mellitus(DM) as a CHD risk equivalent promote the progress of atherosclerosis. It is proved that patient with both CHD and DM more common have multivessel atherosclerosis. Invasive coronary angiography is considered the gold standard for diagnosis of CHD. The noninvasive multislice computed tomography coronary angiography is an almost established coronary imaging technique improving day by day.64-Detector computed tomography angiography in diagnosis and assessment of coronary artery disease-especially for old people with both CHD and DM-is increasingly attentioned.
Objectives:The aim of this study was to investigate the accuracy of 64-slice computed tomography coronary angiography for assessing quality and severity of coronary stenoses in comparison with invasive coronary angiography.
Methods:Fifty-two eldly patients with both CHD and DM, in whom the coronary tree was first studied by 64-detector computed tomography angiography and afterwards, by invasive coronary angiography, were enrolled in the study. All the enhanced scan axial images were processed by multiplanar reconstruction (MPR), volume rendering (VR), maximum intensity projection (MIP), curved planar reconstruction(CPR), vitual endoscopy(VE), and so on. After post-processing, quality and severity of significant coronary stenoses will be assessed. All the patient were accepted invasive coronary angiography in two weeks after being given 64-detector computed tomography angiography. The sensitivity, specificity, predictive positive value and negative predictive value were determined in order to validate the diagnostic accuracy of multislice computed tomography for detection of coronary lesions compared with invasive coronary angiography.
Results:In the fifty-two patients,676 coronary artery segments were assessed, 174 coronary artery segments were detected more than 50% diameter stenosis lesion by invasive coronary angiography, the lesions in 4 patients were minimal stenosis, the rest lesions were severe coronary narrow lesions; the occlusive disease have 11 segments, taking 6.3%; long diasease have 26 segments, taking 14.9%; single-vessel disease taking 19.2%(10/52), two-vessel disease taking 38.5%(20/52), three--vessel disease taking 42.3%(22/52). In 174 coronary artery segments detect more than 50% diameter stenosis lesion by invasive coronary angiography, computed tomography angiography checked out 155 coronary artery segments accurately.The sensitivity, specificity, positive predictive value, and negative predictive value were 89.1%,92.8%,81.2%, and 96.1% respectively per segment. The diagnostic accuracy in patients were very high(91.9%).
Conclusions:64-detector computed tomography coronary angiography can clearly display the left main and the the main branches. Patients with DM more often have multivessel disease and serious lesions.64-detector computed tomography coronary angiography has a very good diagnostic accuracy in our study.
引文
[1]Juutilaine A, Lehto S, Ronnemaa T. Type 2 Diebetes as A "Cornary Heart Disease Equivalent" an 18-Year Prospective Population-based Study in Finish Subjects[J]. Diebetes Care,2007,28:2901-2907.
[2]Windecker S, Maier-Rudolph W, Bonzel T, et al. Interventinal cardiology in Europe 1995. Eur Heart J,1999,20(7):484-495.
[3]King H,Aubert RE, Henman WH:Global burden of diabetes,1995-2005: Prevalence, numerical estimates, and projections. Diabetes Care 21:1414,1998.
[4]赵东,吴兆苏,王薇,等.北京地区1984-1997年急性冠心病事件发病率变化趋势(中国MONICA方案的研究)中华心血管病杂志,2000,28：14-17.
[5]Achenbach S, Ulzheimer S, Baum U, et al. Noninvasive coronary angiography by retrospectively ECG-gated mutislice spiral CT[J]. Circulation,2000,102(12):2823-2828.
[6]Nieman K, Oudkerk M, Rensing B, et al. Coronary Angiography with mutislice computed tomography[J]. Lancet,2001,357(9256):599-603.
[7]Alexander W, Leber AW, Andreas Knez, Franz von Ziegler, et al. Quantification of Obstuctive and Nonobstuctive Coronary Lesion by 64-Slice Computed Tomography, A Comparative Study With Quantitative Coronary Angiography and Intravascular Ultrasound.J Am Coll Cardiol 2005;46:147-54.
[8]Raff GL, Michael J, Glalagher MJ,O'Neil WW, et al. Diagnostic Accuracy of Noninvasive Coranary Angiography Using 64-Slice Computed Tomography. J AM Coll Cardiol 2005:46:552-7.
[9]Mullet NR, Cademartiri F, Nieman K, et al. Multislice spiral CT coronary angiography in patients with stable angina pectoris. J Am Coll Cardiol 2004:43:2265-2270.
[10]黄伟.老年人冠状动脉钙化定量测定的临床意义.实用老年医学[J],2004,18(1)：42-43.
[11]韩志华,何奔,王长谦,等.不稳定型心绞痛患者的血管内超声分析[J].临床心血管病志,2005,21(12)：711-714.
[12]Nicholls S J, Tuzcu E M, Crowe T, et al. Relationship between Cardiovascular Risk Factors and Atherosclerotic Disease Burden Measured by Intravascular Ultrasound [J]. J AM Coll Cardiol,2006, 47:1967-1975.
[13]Schroeder S, Kopp AF, Bauboch A, et al.Noninvasive detection of coronary lesions by multislice computed tomography:result of the new age pilot trail. Catheter Cardiovascular Interv,2001,53(3): 352-358.
[14]Mollet N R, Cadecuartiri F, Colos A G, et al. High-Resolution Spiral Computed Tomography Coronary Angiography in Patients Referred for Diagnostic Convevtional Coronary Angiography [J]. Circulation, 2005,112:2318-2323.
[15]Nieman K, Cademartiri F, Lemos PA, et al. Reliable noninvasive coronary angiography with fast submillimeter multislice spiral computed tomography[J]. Circulation,2002,106:2051-2054.
[1]Kachelriess M, Ulzheimer S, Kalender W. ECG-correlated imgae reconsturction from subsecond multi—slice spiral CT scans of the heart [J]. MedPhys,2000,27:1881-1902.
[2]Achenbach S, Ulzheimer S, Baum U, et al. Noninvasive coronary angiography by retrospectively ECG-gated multi-slice spiral CT [J]. Circulation,2000, 102:2823-2828.
[3]Flohr T, Burder H, StierstorferK, et al. New technical devel-opments in muti-slice CT, part 2:sub-millimeter 16-slice scanning and increased gantry rotation speed for cardiac imaging. Rsfo Fortschr Geb Rontgenstr Neuen Bildgeb Verfahr,2002,174:1022-1027.
[4]Nieman K, Cademartiir F, LemosPA, et al. Reliable noninvasive coronary angiography with fast submillimeter multislice spiral computed tomography[J]. Circulation,2002,106:2051-2054.
[5]Ropers D, Baum U, Pohle K, et al. Detection of coronary atery stenoses with thin-slice multi-detector row spiral computed tomography and multiplanar reconsturction[J]. Circulation,2003,107:664-666.
[6]Raff GL, Glalagher MJ, O'neil WW, et al. Diagnostic accuracy of non—invasive coronary angiography using 64-slice spiral computed tomography [J]. JACC,2005,46.
[7]Mollet NR, Cademartiri F, van Mieghem CA, et al. High resolution spiral computed tomography coronary angiography in patients referred of diagnostic conventional coronary angiography [J]. Circulation,2005,112:2318-2323.
[8]Wintersperger BJ, Nikolaou K. Basics of cardiac MDCT:techniques and contrast application. Review [J]. Eur Radiol,2005,15(Suppl2):B2-B9.
[9]Halliburton SS, Stillman AE, Flohr T, et al. Do segmented reconstruction algorithms for cardiac multi-slice computed tomography improve image qulaity?[J].Herz,2003,28:20-31.
[10]Flohr TG, McCollough CH, Bur der H,et al. First performance evlauation of adual-source CT(DSCT) system [J]. Eur Radiol,2006,16:256-268.
[11]McCollough CH, Primak A, Saba O, et al. Hot topic:dose performance of a new 64-channel dual-soucre(DSCT) scanner [J]. RSNA Annual Meeting, 2005, SSE16-06.
[12]Achenbach S, Ropers D, Holle J, et al. In-plane coronary arterial motion velocity:measurement with electron beam CT [J]. Radiology,2000,216: 457-463.
[13]Achenbach S, Ropers D, Kuettner A, et al. Contrast-enhanced coronary artery visualizationbydual-source computed tomography-initial experience [J]. Eur J Radiol,2006,57:331-335.
[14]Johnson TRC, Nikolaou K, Wintersperger BJ, et al. Dual source cardiac CT imaging:initial experience[J]. Eur Radiol,2006,16:1409-1415.
[15]Harald B, Christof B, Ilias T, et al. Dual—Source CT:efect of heart rate, heart rate variability and calciifcation on imgae quality and diagnostic accuracy[J]. Radiology,2008,247(2):346-355.
[16]Morgan-Hughes GL,Roobottom CA,Owens PE,et al.Highly accurate coronary angiography with submillimetre,16-slice computed tomography [J]. Heart,2005,91(3):308-313.
[17]Becker CR, Ohnesorge BM, Schoepf UT, et al. Current development of cardiac imaging with multi-detector row CT. Eur J Radiol,2000,36(2):97-103.
[18]萧毅,田建明,王培军,等.多层螺旋CT冠脉造影的扫描技术及临床应用.中华放射学杂志,2002,36(4)：357-361.
[19]Wang ZQ, Zhu H, Xia K, et al.The Value of MSCT indetection of coronary artery stenosis.J Comput Assist Tomogr,2001,10(1):16-18.
[20]张辉,张麟,殷宝玲,等.64层螺旋CT冠状动脉成像技术在冠心病诊断中的价值.山东医药,2008,48,(37)67-68.
[21]卢明瑜,刘传芬,胡大一,等.64排螺旋CT冠状动脉成像在冠状动脉病变诊断中的临床研究.中国介入心脏病学杂志,2008,16(2)：100-102.
[2]Windecker S, Maier-Rudolph W, Bonzel T, et al. Interventinal cardiology in Europe 1995. Eur Heart J,1999,20(7):484-495.
[3]King H,Aubert RE, Henman WH:Global burden of diabetes,1995-2005: Prevalence, numerical estimates, and projections. Diabetes Care 21:1414,1998.
[4]赵东,吴兆苏,王薇,等.北京地区1984-1997年急性冠心病事件发病率变化趋势(中国MONICA方案的研究)中华心血管病杂志,2000,28：14-17.
[5]Achenbach S, Ulzheimer S, Baum U, et al. Noninvasive coronary angiography by retrospectively ECG-gated mutislice spiral CT[J]. Circulation,2000,102(12):2823-2828.
[6]Nieman K, Oudkerk M, Rensing B, et al. Coronary Angiography with mutislice computed tomography[J]. Lancet,2001,357(9256):599-603.
[7]Alexander W, Leber AW, Andreas Knez, Franz von Ziegler, et al. Quantification of Obstuctive and Nonobstuctive Coronary Lesion by 64-Slice Computed Tomography, A Comparative Study With Quantitative Coronary Angiography and Intravascular Ultrasound.J Am Coll Cardiol 2005;46:147-54.
[8]Raff GL, Michael J, Glalagher MJ,O'Neil WW, et al. Diagnostic Accuracy of Noninvasive Coranary Angiography Using 64-Slice Computed Tomography. J AM Coll Cardiol 2005:46:552-7.
[9]Mullet NR, Cademartiri F, Nieman K, et al. Multislice spiral CT coronary angiography in patients with stable angina pectoris. J Am Coll Cardiol 2004:43:2265-2270.
[10]黄伟.老年人冠状动脉钙化定量测定的临床意义.实用老年医学[J],2004,18(1)：42-43.
[11]韩志华,何奔,王长谦,等.不稳定型心绞痛患者的血管内超声分析[J].临床心血管病志,2005,21(12)：711-714.
[12]Nicholls S J, Tuzcu E M, Crowe T, et al. Relationship between Cardiovascular Risk Factors and Atherosclerotic Disease Burden Measured by Intravascular Ultrasound [J]. J AM Coll Cardiol,2006, 47:1967-1975.
[13]Schroeder S, Kopp AF, Bauboch A, et al.Noninvasive detection of coronary lesions by multislice computed tomography:result of the new age pilot trail. Catheter Cardiovascular Interv,2001,53(3): 352-358.
[14]Mollet N R, Cadecuartiri F, Colos A G, et al. High-Resolution Spiral Computed Tomography Coronary Angiography in Patients Referred for Diagnostic Convevtional Coronary Angiography [J]. Circulation, 2005,112:2318-2323.
[15]Nieman K, Cademartiri F, Lemos PA, et al. Reliable noninvasive coronary angiography with fast submillimeter multislice spiral computed tomography[J]. Circulation,2002,106:2051-2054.
[1]Kachelriess M, Ulzheimer S, Kalender W. ECG-correlated imgae reconsturction from subsecond multi—slice spiral CT scans of the heart [J]. MedPhys,2000,27:1881-1902.
[2]Achenbach S, Ulzheimer S, Baum U, et al. Noninvasive coronary angiography by retrospectively ECG-gated multi-slice spiral CT [J]. Circulation,2000, 102:2823-2828.
[3]Flohr T, Burder H, StierstorferK, et al. New technical devel-opments in muti-slice CT, part 2:sub-millimeter 16-slice scanning and increased gantry rotation speed for cardiac imaging. Rsfo Fortschr Geb Rontgenstr Neuen Bildgeb Verfahr,2002,174:1022-1027.
[4]Nieman K, Cademartiir F, LemosPA, et al. Reliable noninvasive coronary angiography with fast submillimeter multislice spiral computed tomography[J]. Circulation,2002,106:2051-2054.
[5]Ropers D, Baum U, Pohle K, et al. Detection of coronary atery stenoses with thin-slice multi-detector row spiral computed tomography and multiplanar reconsturction[J]. Circulation,2003,107:664-666.
[6]Raff GL, Glalagher MJ, O'neil WW, et al. Diagnostic accuracy of non—invasive coronary angiography using 64-slice spiral computed tomography [J]. JACC,2005,46.
[7]Mollet NR, Cademartiri F, van Mieghem CA, et al. High resolution spiral computed tomography coronary angiography in patients referred of diagnostic conventional coronary angiography [J]. Circulation,2005,112:2318-2323.
[8]Wintersperger BJ, Nikolaou K. Basics of cardiac MDCT:techniques and contrast application. Review [J]. Eur Radiol,2005,15(Suppl2):B2-B9.
[9]Halliburton SS, Stillman AE, Flohr T, et al. Do segmented reconstruction algorithms for cardiac multi-slice computed tomography improve image qulaity?[J].Herz,2003,28:20-31.
[10]Flohr TG, McCollough CH, Bur der H,et al. First performance evlauation of adual-source CT(DSCT) system [J]. Eur Radiol,2006,16:256-268.
[11]McCollough CH, Primak A, Saba O, et al. Hot topic:dose performance of a new 64-channel dual-soucre(DSCT) scanner [J]. RSNA Annual Meeting, 2005, SSE16-06.
[12]Achenbach S, Ropers D, Holle J, et al. In-plane coronary arterial motion velocity:measurement with electron beam CT [J]. Radiology,2000,216: 457-463.
[13]Achenbach S, Ropers D, Kuettner A, et al. Contrast-enhanced coronary artery visualizationbydual-source computed tomography-initial experience [J]. Eur J Radiol,2006,57:331-335.
[14]Johnson TRC, Nikolaou K, Wintersperger BJ, et al. Dual source cardiac CT imaging:initial experience[J]. Eur Radiol,2006,16:1409-1415.
[15]Harald B, Christof B, Ilias T, et al. Dual—Source CT:efect of heart rate, heart rate variability and calciifcation on imgae quality and diagnostic accuracy[J]. Radiology,2008,247(2):346-355.
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