冠心病平板运动试验Duke评分与冠状动脉造影及冠状动脉64层螺旋CT的相关性研究
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摘要
冠心病的临床诊断技术经历了漫长的发展过程,其中心电图是冠心病诊断中最早、最常用和最基本的诊断方法。与其他诊断方法相比,心电图使用方便,易于普及,当患者病情变化时便可及时捕捉其变化情况,并能连续动态观察和进行各种负荷试验,以提高其诊断敏感性。无论是心绞痛或心肌梗死,都有其典型的心电图变化,特别是对心律失常的诊断更有其临床价值,当然也存在着一定的局限性。心电图负荷试验主要包括运动负荷试验和药物试验(如潘生丁、异丙肾试验等)。是临床观察心肌缺血最常用的简易方法。其中平板运动试验是近年来临床上常用的方法。近年来有关冠心病诊断的各种新方法不断应用于临床,平板运动试验Duke评分是对冠心病进行诊断、危险分层和预后评估最有效、最重要的非侵入性诊断技术之一。冠状动脉造影是近年来广泛应用于临床的诊断冠心病的有创技术,被公认为诊断冠心病的“金标准”,但其亦属有创性技术。自2004年64层螺旋CT问世以来,因为其具备的0.4mm的高分辨率、83-165ms快速旋转速度以及三维计算机后处理技术,使得快速运动的器官,如冠状动脉和心脏的解剖结构以及病理改变在无创的血管造影诊断上成为可能。64层螺旋CT冠状动脉成像判断冠状动脉狭窄的准确性一直是研究的热点,以传统冠状动脉造影术为参考标准,64层螺旋CT判断冠状动脉狭窄性病变具有较高的阴性预测值。
本试验通过平板运动试验Duke评分、冠状动脉造影及64层螺旋CT在冠心病诊断上的应用,得到如下结论:(1)按照平板运动试验Duke评分≥5分(低危)和＜5分(中高危)所分的2组中患者的性别、合并高血压、糖尿病的比例差异无统计学意义(P＞0.05);中高危组患者平均年龄较低危组大,差异有统计学意义(P＜0.05)。(2)CAG检验Duke评分≥5分(低危组)和＜5分(中高危组)冠状动脉病变例数。结果显示,Duke评分低危组三支冠状动脉病变例数明显小于中高危组。(3)64层螺旋CT与冠状动脉造影诊断不同位置冠状动脉病变比较差异无统计学意义。(4)以冠状动脉造影为诊断冠心病的金标准,本研究64层螺旋CT诊断冠心病的敏感度94.7%、特异度87.8%、准确度94.6%、阳性预测值96.4%、阴性预测值82.0%。5、64层螺旋CT与冠状动脉造影显示冠状动脉内斑块情况比较差异无统计学意义。6、平板运动试验Duke评分、64层螺旋CT较冠状动脉造影具有某些特殊优势,前二者在诊断冠心病上具有无创性,尤其平板运动试验Duke评分可以广泛应用于临床,具有良好的普及性和筛选能力。
Background:
Diagnose of coronary heart disease(CHD) mainly depend on typical clinical situation and coherent auxiliary examination of patients.All kinds of new methods about CHD were applying to clinic in recent years.Duke treadmill score(DTS) is one of the most effective and important non-invasive diagnostic techniques of diagnosis,risk stratification and prognostic assessment to CHD.In recent years,coronary angiography(CAG) is a traumatic technique which was widely used in clinical diagnosis of CHD,and was recognized as the "gold standard" of diagnosis of CHD.But it is also an invasive technique.64-slice siral CT allows the non-invasive angiography diagnosis of anatomic structure and pathological changes with quick movement organs such as arteria coranaria and heart to become possible.DTS,CAG and 64-slice siral CT are the current research focus in the assessment of diagnostic value for CHD.
Objective:
To evaluation the diagnostic value for CHD through the application of DTS, CAG and 64-slice spiral CT in the diagnosis of CHD,then provide experimental basis for clinical diagnostic methods.
Method:
Collected 89 patients continuously from May 2007 to April 2008 witch ECG exercise stress test(exercise treadmill test) were positive in our hospital. Duke score was given respective.61 patients were scaned by 64-slice spiral CT in a week and 65 patients were detected by CAG.61 patients were bring into research object according to including and excluding standard.
1.All the selected research objects stop taking drugs witch could impact the heart rate,antianginal drugs and digitaloid drugs before treadmill exercise test at least three days.Submaximal exercise test was practised according to standard Bruce scheme.ECG with 12 leads was recorded before and after movement and every 1-2min.Duke score=exercise time-5×ST-segment depression extent-4×angina index.
2.All patients were operated with CAG through 6F visualization ductus. And image was gathered through siemens C arm digital subtraction radiography AXIMO Artis,speed was 12.5 frame/s.The degree of coronary artery stenosis was evaluated by two veteran intervention doctors.
3.Post-electro cardio-gating cardiac scanner mode and Intell fan- shaped selective scanner mode were provided to all patients.Scan range was from windpipe eminence to diaphragmatic surface of heart.Taking diagnosis by traditional CAG as reference standard,to evaluate the diagnosis accuracy of≥50%and≥70%coronary artery stenosis result from affection of coronary artery calcified plaque,blending plaque and non- calcified plaque by 64-slice siral CT respectively.Taking the extent of coronary artery stenosis±10%by CAG as eference standard,to evaluate the coincidence of the diagnosis of coronary artery stenosis by 64-slice spiral CT.
Result:
1.Difference of patients who belong to low-risk group(DTS≥5) and belong to mod or high-risk group(DTS＜5) in sex composition and in percentage of HBP and DM complication were not statistically significant(P＞0.05).Mean age of patients who belong to mod or high-risk group was older than that of patients belong to low-risk group,and the difference was statistically significant (P＜0.05).
2.To test affection instances of aeteria coronaria by CAG of patients who belong to low-risk group(DTS≥5) and belong to mod or high-risk group (DTS＜5).It was shown that affection instances of three aeteria coronaria of patients who belong to low-risk group were obvious fewer than that of patients who belong to mod or high-risk group.
3.Diagnosis of affection of aeteria coronaria in different location by 64-slice spiral CT was not statistically significant than that by CAG.
4.Taken CAG as the gold standard in diagnosing CHD,the diagnosis sensitivity of CHD by 64-slice spiral CT was 96.8%,secificity was 88.9%, accuracy rating was 95.8%,positive predictive value was 98.4%and negative predictive value was 80.1%in our studies.
5.Plaque display in aeteria coronaria by 64-slice spiral CT was not statistically significant than that by CAG.
Conclusion:
1.Risk layer by DTS after CAG was definitive significant in diagnosis of different ramus affection of aeteria coronaria.
2.Coincidence between the diagnosis of coronary artery stenosis by 64-slice spiral CT and the reference standard which come from the extent of coronary artery stenosis±10%by CAG was good.
3.CAG was still the gold standard as coronary artery stenosis.
4.Clinically taking DTS association with one of CAG and 64-slice spiral CT as the method of the diagnosis of CHD shew satisfactory specificity and accuracy rating.
本试验通过平板运动试验Duke评分、冠状动脉造影及64层螺旋CT在冠心病诊断上的应用,得到如下结论:(1)按照平板运动试验Duke评分≥5分(低危)和＜5分(中高危)所分的2组中患者的性别、合并高血压、糖尿病的比例差异无统计学意义(P＞0.05);中高危组患者平均年龄较低危组大,差异有统计学意义(P＜0.05)。(2)CAG检验Duke评分≥5分(低危组)和＜5分(中高危组)冠状动脉病变例数。结果显示,Duke评分低危组三支冠状动脉病变例数明显小于中高危组。(3)64层螺旋CT与冠状动脉造影诊断不同位置冠状动脉病变比较差异无统计学意义。(4)以冠状动脉造影为诊断冠心病的金标准,本研究64层螺旋CT诊断冠心病的敏感度94.7%、特异度87.8%、准确度94.6%、阳性预测值96.4%、阴性预测值82.0%。5、64层螺旋CT与冠状动脉造影显示冠状动脉内斑块情况比较差异无统计学意义。6、平板运动试验Duke评分、64层螺旋CT较冠状动脉造影具有某些特殊优势,前二者在诊断冠心病上具有无创性,尤其平板运动试验Duke评分可以广泛应用于临床,具有良好的普及性和筛选能力。
Background:
Diagnose of coronary heart disease(CHD) mainly depend on typical clinical situation and coherent auxiliary examination of patients.All kinds of new methods about CHD were applying to clinic in recent years.Duke treadmill score(DTS) is one of the most effective and important non-invasive diagnostic techniques of diagnosis,risk stratification and prognostic assessment to CHD.In recent years,coronary angiography(CAG) is a traumatic technique which was widely used in clinical diagnosis of CHD,and was recognized as the "gold standard" of diagnosis of CHD.But it is also an invasive technique.64-slice siral CT allows the non-invasive angiography diagnosis of anatomic structure and pathological changes with quick movement organs such as arteria coranaria and heart to become possible.DTS,CAG and 64-slice siral CT are the current research focus in the assessment of diagnostic value for CHD.
Objective:
To evaluation the diagnostic value for CHD through the application of DTS, CAG and 64-slice spiral CT in the diagnosis of CHD,then provide experimental basis for clinical diagnostic methods.
Method:
Collected 89 patients continuously from May 2007 to April 2008 witch ECG exercise stress test(exercise treadmill test) were positive in our hospital. Duke score was given respective.61 patients were scaned by 64-slice spiral CT in a week and 65 patients were detected by CAG.61 patients were bring into research object according to including and excluding standard.
1.All the selected research objects stop taking drugs witch could impact the heart rate,antianginal drugs and digitaloid drugs before treadmill exercise test at least three days.Submaximal exercise test was practised according to standard Bruce scheme.ECG with 12 leads was recorded before and after movement and every 1-2min.Duke score=exercise time-5×ST-segment depression extent-4×angina index.
2.All patients were operated with CAG through 6F visualization ductus. And image was gathered through siemens C arm digital subtraction radiography AXIMO Artis,speed was 12.5 frame/s.The degree of coronary artery stenosis was evaluated by two veteran intervention doctors.
3.Post-electro cardio-gating cardiac scanner mode and Intell fan- shaped selective scanner mode were provided to all patients.Scan range was from windpipe eminence to diaphragmatic surface of heart.Taking diagnosis by traditional CAG as reference standard,to evaluate the diagnosis accuracy of≥50%and≥70%coronary artery stenosis result from affection of coronary artery calcified plaque,blending plaque and non- calcified plaque by 64-slice siral CT respectively.Taking the extent of coronary artery stenosis±10%by CAG as eference standard,to evaluate the coincidence of the diagnosis of coronary artery stenosis by 64-slice spiral CT.
Result:
1.Difference of patients who belong to low-risk group(DTS≥5) and belong to mod or high-risk group(DTS＜5) in sex composition and in percentage of HBP and DM complication were not statistically significant(P＞0.05).Mean age of patients who belong to mod or high-risk group was older than that of patients belong to low-risk group,and the difference was statistically significant (P＜0.05).
2.To test affection instances of aeteria coronaria by CAG of patients who belong to low-risk group(DTS≥5) and belong to mod or high-risk group (DTS＜5).It was shown that affection instances of three aeteria coronaria of patients who belong to low-risk group were obvious fewer than that of patients who belong to mod or high-risk group.
3.Diagnosis of affection of aeteria coronaria in different location by 64-slice spiral CT was not statistically significant than that by CAG.
4.Taken CAG as the gold standard in diagnosing CHD,the diagnosis sensitivity of CHD by 64-slice spiral CT was 96.8%,secificity was 88.9%, accuracy rating was 95.8%,positive predictive value was 98.4%and negative predictive value was 80.1%in our studies.
5.Plaque display in aeteria coronaria by 64-slice spiral CT was not statistically significant than that by CAG.
Conclusion:
1.Risk layer by DTS after CAG was definitive significant in diagnosis of different ramus affection of aeteria coronaria.
2.Coincidence between the diagnosis of coronary artery stenosis by 64-slice spiral CT and the reference standard which come from the extent of coronary artery stenosis±10%by CAG was good.
3.CAG was still the gold standard as coronary artery stenosis.
4.Clinically taking DTS association with one of CAG and 64-slice spiral CT as the method of the diagnosis of CHD shew satisfactory specificity and accuracy rating.
引文
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[2]Bharadwaj D,Stein MP,Volzer M,et al.The major receptor for C-reactive proteinon leukocytes is fcgamma receptor Ⅱ[J].J Ex Med,1999,190(4):585-590.
[3]Blankenberg S,Tiret L,Bickel C.Interleukin-18 is a strong predictor of cardiovascular death in stable and unstable angina[J].Circulation,2002,106(1):24-30.
[4]Weissberg PL.Atherogenesis current understanding of the cause of atheroma[J].Hear,2000,83(1):247-252.
[5]Busse WW,Lemanske RF Jr.Asthma[J].N Engl J Med,2001,344(5):350-362.
[6]Takagi S,Goto Y,Hirose E,et al.Successful treatment of refractory vasospastic angina with corticosteroids:coronary arterialhyperac-tivity caused by local inflammation[J].Circ J,2004,68(1):17-22.
[7]Li JJ,Nie SP,Xu B,et al.Inflammation in variant angina:is there any evidence[J]? Med Hypotheses,2007,68(3):635-640.
[8]Katayama N,Nakao K,Horiuchi K,et al.Disease activities and serum C-reactiveprotein levels in patients with vasospastic angina pectoris[J].J Cardio,2005,46(2):63-70.
[9]Croce K,Libby P.Intertwining of thrombosis and inflammation in atherosclerosis[J].Curr Opin Hemato,2007,4(1):55-61.
[10]Strukova S.Blood coagulation-dependent inflammation and inflammation -dependent thrombosis[J].Front Biosc,2006,11:59-80.
[11]Chu AJ.Tissue factormediates inflammation[J].Arch Biochem Biohys,2005,440(2):123-132.
[12]Merten M,Thiagarajan P.P-selectin in arterial thrombosis[J].Zkardiol 2004,93(11):855-863.
[13]罗敏.胰岛素抵抗与动脉粥样硬化[J].中华内科杂志,2002,41(9):636.
[14]Krempler F,Breban D,Oberkofler H,et al.Leptin peroxisome proliferator-activated receptor gamma,and CCAAT/enhancer binding protein alha m-RNA expression in adipose tissue of humans and their relation to cardiovascular risk factors[J].Arterioscler Thromb Vasc Bio,2000,20(2):443-449.
[15]张政祥,李红辉,陈家林,等.血清瘦素与原发性高血压和体脂及血脂的关系研究[J].高血压杂志,2002,10(2):110-113.
[16]Al-Daghri N,Al-Rubean K,Bartlett WA,et al.Serum leptin is elevated in Saudi Arabian patients with metabolic syndrome and coronary artery disease[J].Diabet Meal,2003,20:832-837.
[17]Reilly MP,Iqbal N,Schutta M,et al.Plasma leptin levels are associated with coronary atherosclerosis in type 2 diabetes[J].J Clin Endocrinol Metab,2004,89(8):3872-3878.
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