腺苷负荷心肌灌注显像及双源CT冠脉成像在冠心病诊断中的价值

腺苷负荷心肌灌注显像与双源CT冠脉成像在冠心病诊断中的价值摘要目的探讨腺苷(ADE)负荷心肌灌注显像(Myocardial Perfusion Imaging, MPI)与双源CT(Dual-Source Computed Tomography, DSCT) 冠脉成像在冠心病(Coronary Heart Disease, CHD)诊断中的价值及相互关系。

方法选择CHD为中到高度可能性的患者115例，行静息(Rest)、ADE负荷门控MPI及DSCT冠脉成像，其中32例患者同期进行了冠状动脉造影术（Coronary Angiogra- phy, CAG)。

MPI结果采用美国心脏病协会17节段5分制 (0~4 分) 目测半定量及定性方法进行分析，将SD S≥2分的心肌节段确定为可逆性缺损（Reversible Defect, RD）。

缺损的严重程度分为5级：正常、轻度、中度和重度放射性减低及放射性缺损，并将各心肌节段定位于其所对应的冠状动脉。

DSCT采用国际通用的目测直径法判断冠脉狭窄程度并分为：正常、狭窄<50%、50~69%、70%~99%及闭塞性病变，狭窄程度≥50%时定义为CHD。

以CAG结果为“金标准”，比较MPI和DSCT对CHD的诊断价值，并对115例患者的MPI和DSCT结果进行对比分析。

结果32例患者：根据CAG结果，MPI和DSCT对CHD患者诊断的敏感性、特异性及准确性分别为95.65%、66.67%、87.5%及82.6%、77.8%、81.25%。

两种方法联合诊断的敏感性、特异性及准确性分别为100%、88.9%及96.8%。

两者诊断CHD的差异无统计学意义，χ2 =0.164, P>0.05。

115例患者：MPI显示109支冠脉对应的室壁节段出现放射性减低或缺损，DSCT显示有103支冠脉狭窄。

DSCT显示的103支狭窄冠脉中有71支冠脉对应的心肌室壁节段出现放射性减低或缺损。

在狭窄<50%、50%~69%、70%~99%及闭塞性病变的狭窄冠脉中MPI分别显示有55.56%、71.43%、80.77%及83.3%的冠脉供血区呈放射性减低或缺损。

<50%的狭窄冠脉对应的室壁节段放射性轻度、中度、重度减低分别占20%、75%、5%；50% ~ 69%的狭窄冠脉对应的室壁节段放射性轻度、中度、重度减低分别占8%、52%、40%；70% ~ 99%的狭窄冠脉对应的室壁放射性中度、重度减低和放射性缺损分别占33.3%、47.6%、19.0%。

闭塞性病变中重度放射性减低占40%，放射性缺损占60%。

结论 1. MPI和DSCT冠脉成像在CHD诊断中均有较高的诊断价值。

两种方法结合使用，可明显提高诊断CHD的敏感性、特异性、准确性、阳性和阴性预测价值。

2. MPI 和DSCT冠脉成像均阴性者患CHD可能性很小，均阳性者患CHD可能性很大。

两者作为筛选和诊断CHD的方法，可使近半数的患者避免CAG带来的创伤，节省有限的医疗费用。

3. MPI能检出部分心肌微血管病变患者，同时可提供狭窄冠脉的血流动力学变化，为临床医师治疗决策提供依据。

关键词MPI，DSCT冠脉成像，CHD，CAGDiagnostic Value of Adenosine Stress Myocardial PerfusionImaging Compared with Dual -Source Computed tomographyfor detecting Coronary Heart DiseaseABSTRACTObjective Discussion of Adenosine (ADE) stress myocardial perfusion imaging (Myocardial Perfusion Imaging, MPI) and Dual-Source CT (Dual-Source Computed Tomogranhy, DSCT) coronary artery imaging in coronary heart disease (Coronary Heart Diseas, CHD) diagnosis of value and mutual relations.Methods CHD choice for medium to high probability of 115 cases of patients, the resting (REST), ADE stress gated MPI and DSCT coronary imaging, in the same period 32 patients had coronary angiography (CAG). MPI results using the American Heart Association 17 segment 5-point scale (0 to 4 points) visual semi-quantitative and qualitative methods, using semi-quantitative method to analyze the results of the MPI will be sub-SDS ≥ 2 myocardial segments identified as reversible defect ( Reversible Defect, RD).The seriousness of defect sub-divided into 5: normal, mild, moderate and severe radiatioactive reduce and radioactive defects, and the myocardial segments corresponding position in their coronary. DSCT visual use of international common law to determine the diameter of coronary stenosis and is divided into: normal，stenosis <50%, 50~69%, 70%~99% and occlusive disease, stenosis ≥ 50% when defined as a CHD. CAG results in "gold standard", MPI and DSCT compared the diagnostic value of CHD and 115 cases of patients with the results of MPI and a comparative analysis of DSCT.Results 32 cases of patients according to CAG results, MPI and DSCT diagnosis of CHD in patients with sensitivity, specificity and accuracy were 95.65%, 66.67%, 87.5% and82.65%, 77.8%, 81.25%. Joint diagnosis of the two methods of sensitivity, specificity and accuracy were 100%, 88.9% and 96.8%. Diagnosis of CHD between the difference was not statistically significant, χ2 = 0.164, P> 0.05. 115 cases of patients with: MPI showed that 109 coronary artery segments corresponding wall myocardial perfusion defect appears, DSCT showed coronary stenosis 103. 103 coronary artery stenosis in 71 corresponding myocardial wall coronary segments showed myocardial perfusion defect. Narrow <50%, 50%~69%, 70%~99% and occlusive disease of the MPI, respectively, in coronary artery stenosis showed that 55.56%, 71.43%, 80.77%and 83.3% of the coronary blood supply to reduce the area was radioactive; <50% stenosis of the coronary artery corresponding radioactive wall segments mild, moderate, severe reduction: 20%, 75%, 5%, respectively. 50% ~ 69% stenosis of coronary segments corresponding radioactive wall mild, moderate, severe reduction : 8%, 52%, 40%, respectively. 70% ~ 99% of stenosis coronary artery corresponding radioactive wall: moderate and severe defects and radiation defect the respective shares of 33.3%, 47.6%, 19.0%. Occlusive disease: severe radioactive reduction and defect the shares of 40%, 60% .Conclusion 1. MPI and DSCT coronary imaging in the diagnosis of CHD had a higher diagnosis value. A combination of both methods can significantly improve the diagnosis of CHD The sensitivity, specificity, accuracy, positive and negative predictive value. 2 . MPI and DSCT coronary imaging are negative the possibility of suffering from CHD is very small, both positive CHD risk is very high. Both screening and diagnosis of CHD as a way to make nearly half of the patients to avoid the trauma caused by CAG, saving the cost of limited medical 3. MPI can be detected in some patients with myocardial microvascular disease, coronary artery stenosis at the same time provides the hemodynamic changes, the treatment decision-making for clinicians to provide a basis.KEYWORDS MPI, DSCT coronary imaging, CHD, CAG中英文缩略词表英文缩略词英文全称中文译名MPI Myocardial Perfusion Imaging 心肌灌注显像双源计算机断层扫描TomographyDSCT Dual-SourceComputedIsonitrile 甲氧基异丁基异氰MIBI MethoxyisobutylCAG CoronaryAngiography 选择性冠状动脉造影SSS Summed Strest Score 负荷像总分SRS Summed Rest Score 静息显像总分SDS Summed Different Score 总差值分ADE Adenosine 腺苷FD Fixed Defect, FD 固定性缺损RD Reversible Defect, RD 可逆性缺损SPECT Single-photon Emission Computed 单光子发射式计算机断层CoronaryArtery 右冠状动脉RCA RightLAD Left Anterior Descending Branch 左前降支LCX Left Circumflex Branch 左回旋支Technique 容积再现技术RenderingVRT V olumeHeartAssociation 美国心脏病协会AHA AmericaReformations 多平面重建MPR Multi-planarMIP Maximum Intensity Projection 最大密度投影CPR Curved Planar Reconstruction 曲面重建前言冠心病（Coronary Heart Diease, CHD）即冠状动脉粥样硬化性心脏病，指冠状动脉粥样硬化使血管腔狭窄或阻塞，或（和）因冠状动脉功能性改变（痉挛）导致心肌缺血缺氧或坏死而引起的心脏病[1]。