冠状动脉CT——从解剖学迈入功能学的新时代
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摘要
冠状动脉CT血管成像(CCTA)是评价冠心病的重要检查手段,可以提供钙化、斑块以及病变周围脂肪的特征。虽然CCTA具有较高的阴性预测值,但在诊断缺血性病变方面的特异性较低。近年来,CT技术取得了巨大进步,出现的多种功能CT技术不断发展,如冠状动脉跨腔衰减梯度、CT血流储备分数和CT心肌灌注成像,可以提供血流动力学信息。文中对心脏CT技术在进入功能诊断时代的发展和热点问题进行阐述。
Coronary computed tomography(CCTA)has become an important modality in the evaluation of coronary artery disease(CAD). CCTA is able to evaluate beyond the lumen in characterizing and quantifying atherosclerotic plaques,including fea?tures of calcification and fat around lesions. Although CCTA has high negative predictive value to exclude obstructive CAD,it has low specificity in the diagnosis of ischemia-inducing lesions. Recent advances in CT technology have resulted in the development of multi?ple functional CT techniques to provide hemodynamic information,such as coronary transluminal attenuation gradient(TAG),CT-de?rived fractional flow reserve(CT-FFR),computational fluid dynamics(CFD)and CT perfusion(CTP). In this article,we provide a perspective on these cardiac CT techniques in the evaluation of CAD.
Coronary computed tomography(CCTA)has become an important modality in the evaluation of coronary artery disease(CAD). CCTA is able to evaluate beyond the lumen in characterizing and quantifying atherosclerotic plaques,including fea?tures of calcification and fat around lesions. Although CCTA has high negative predictive value to exclude obstructive CAD,it has low specificity in the diagnosis of ischemia-inducing lesions. Recent advances in CT technology have resulted in the development of multi?ple functional CT techniques to provide hemodynamic information,such as coronary transluminal attenuation gradient(TAG),CT-de?rived fractional flow reserve(CT-FFR),computational fluid dynamics(CFD)and CT perfusion(CTP). In this article,we provide a perspective on these cardiac CT techniques in the evaluation of CAD.
引文
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[16]Norgaard BL,Terkelsen CJ,Mathiassen ON,et al.Coronary CT angiographic and flow reserve-guided management of patients with stable ischemic heart disease[J].J Am Coll Cardiol,2018,72(18):2123-2134.
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[2]Silverman MG,Blaha MJ,Krumholz HM,et al.Impact of coronary artery calcium on coronary heart disease events in individuals at the extremes of traditional risk factor burden:the Multi-Ethnic Study of Atherosclerosis[J].Eur Heart J,2014,35(33):2232-2241.
[3]Montalescot G,Sechtem U,Achenbach S,et al.2013 ESC guidelines on the management of stable coronary artery disease:the task force on the management of stable coronary artery disease of the European Society of Cardiology[J].Eur Heart J,2013,34(38):2949-3003.
[4]Hoffmann U,Ferencik M,Udelson JE,et al.Prognostic value of noninvasive cardiovascular testing in patients with stable chest pain:insights from the promise trial[J].Circulation,2017,135(24):2320-2332.
[5]Finck T,Hardenberg J,Will A,et al.Ten-year follow-up after coronary computed tomography angiography in patients with suspected coronary artery disease[J].JACC Cardiovasc Imaging,2018,[Epub ahead of print].
[6]Libby,Peter.Mechanisms of acute coronary syndromes and their implications for therapy[J].N Engl J Med,2013,368:2004-2013.
[7]Ferencik M,Mayrhofer T,Bittner DO,et al.Use of high-risk coronary atherosclerotic plaque detection for risk stratification of patients with stable chest pain:a secondary analysis of the promise randomized clinical trial[J].JAMA Cardiol,2018,3(2):144-152.
[8]Oikonomou EK,Marwan M,Desai MY,et al.Non-invasive detection of coronary inflammation using computed tomography and prediction of residual cardiovascular risk(the CRISP CT study):a post-hoc analysis of prospective outcome data[J].Lancet,2018,392(10151):929-939.
[9]Goeller M,Achenbach S,Cadet S,et al.Pericoronary adipose tissue computed tomography attenuation and high-risk plaque characteristics in acute coronary syndrome compared with stable coronary artery disease[J].JAMA Cardiol,2018,3(9):858-863.
[10]Wong DTL,Ko BS,Cameron JD,et al.Transluminal attenuation gradient in coronary computed tomography angiography is a novel noninvasive approach to the identification of functionally significant coronary artery stenosis:a comparison with fractional flow reserve[J].J Am Coll Cardiol,2013,61(12):1271-1279.
[11]Gao Y,Lu B,Hou ZH,et al.Coronary in-stent restenosis:Assessment with corrected coronary opacification difference across coronary stents measured with CT angiography[J].Radiology,2015,275(2):403-412.
[12]Choi JH,Kim EK,Kim SM,et al.Noninvasive discrimination of coronary chronic total occlusion and subtotal occlusion by coronary computed tomography angiography[J].JACC Cardiovasc Interv,2015,8(9):1143-1153.
[13]Celeng C,Leiner T,Maurovich-Horvat P,et al.Anatomical and functional computed tomography for diagnosing hemodynamically significant coronary artery disease:a meta-analysis[J].JACC Cardiovasc Imaging,2018,[Epub ahead of print].
[14]Douglas PS,De Bruyne B,Pontone G,et al.1-year outcomes of FFRCT-guided care in patients with suspected coronary disease:the PLAT-FORM study[J].J Am Coll Cardiol,2016,68(5):435-445.
[15]Fairbairn TA,Nieman K,Akasaka T,et al.Real-world clinical utility and impact on clinical decision-making of coronary computed tomography angiography-derived fractional flow reserve:lessons from the ADVANCE Registry[J].Eur Heart J,2018,39(41):3701-3711.
[16]Norgaard BL,Terkelsen CJ,Mathiassen ON,et al.Coronary CT angiographic and flow reserve-guided management of patients with stable ischemic heart disease[J].J Am Coll Cardiol,2018,72(18):2123-2134.
[17]Kwak BR,Back M,Bochaton-Piallat ML,et al.Biomechanical factors in atherosclerosis:mechanisms and clinical implications[J].Eur Heart J,2014,35(43):3013-3020.
[18]Choi G,Lee JM,Kim HJ,et al.Coronary artery axial plaque stress and its relationship with lesion geometry:application of computational fluid dynamics to coronary CT angiography[J].JACC Cardiovasc Imaging,2015,8(10):1156-1166.
[19]Lee JM,Choi G,Koo BK,et al.Identification of high-risk plaques destined to cause acute coronary syndrome using coronary computed tomographic angiography and computational fluid dynamics[J].JACC Cardiovasc Imaging,2018,[Epub ahead of print].
[20]Rochitte CE,George RT,Chen MY,et al.Computed tomography angiography and perfusion to assess coronary artery stenosis causing perfusion defects by single photon emission computed tomography:the CORE320 study[J].Eur Heart J,2014,35(17):1120-1130.
[21]Rief M,Chen MY,Vavere AL,et al.Coronary artery disease:analysis of diagnostic performance of CT perfusion and MR perfusion imaging in comparison with quantitative coronary angiography and spect-multicenter prospective trial[J].Radiology,2017,286(2):461-470.