Coronary CT Angiography and 5-Year Risk of Myocardial Infarction
Coronary CT Angiography and 5-Year Risk of Myocardial Infarction
复制标题
DOI：
10.1056/nejmoa1805971
复制
发表时间：
2018-09-06
影响因子：
158.5
通讯作者：
Williams, Michelle C.
中科院分区：
文献类型：
--
作者：
Newby, David E.;Adamson, Philip D.;Williams, Michelle C.
背景虽然冠状动脉CT血管造影(CTA)提高了对稳定性胸痛患者的诊断确定性，但其对5年临床结果的影响尚不清楚。方法：在一项开放、多中心、平行分组的开放试验中，我们随机将4146名已转诊至心脏科诊所进行评估的稳定性胸痛患者分为标准护理加CTA组(2073例)和单纯标准护理组(2073例)。对调查、治疗和临床结果进行3到7年的随访评估。主要终点是5年死于冠心病或非致命性心肌梗死。结果平均随访时间为4.8年，平均随访时间为20254人年。CTA组的5年主要终点发生率低于标准护理组(2.3%[48例患者]vs.3.9%[81例患者]；危险比0.59；95%可信区间0.41至0.84；P=0.004)。尽管在最初几个月的随访中，CTA组的有创冠状动脉造影率和冠状动脉血运重建率高于标准护理组，但5年的总发生率相似：CTA组和标准护理组分别有491名患者和502名患者接受了有创冠状动脉造影术(风险比为1.00；95%CI，0.88至1.13)，279名患者和267名患者接受了冠状动脉血管重建(风险比，1.07；95%CI，0.91至1.27)。然而，CTA组患者启动了更多的预防性治疗(优势比，1.40；95%CI，1.19至1.65)，以及更多的抗心绞痛治疗(优势比，1.27；95%CI，1.05至1.54)。组内心血管或非心血管死亡或因任何原因死亡的比率没有显著差异。结论在本试验中，在本试验中，在对稳定性胸痛患者进行标准护理的基础上，使用CTA可显著降低5年后冠心病或非致命性心肌梗死的死亡率，而不会导致冠状动脉造影术或冠状动脉血运重建率显著升高。
BACKGROUNDAlthough coronary computed tomographic angiography (CTA) improves diagnostic certainty in the assessment of patients with stable chest pain, its effect on 5-year clinical outcomes is unknown.METHODSIn an open-label, multicenter, parallel-group trial, we randomly assigned 4146 patients with stable chest pain who had been referred to a cardiology clinic for evaluation to standard care plus CTA (2073 patients) or to standard care alone (2073 patients). Investigations, treatments, and clinical outcomes were assessed over 3 to 7 years of follow-up. The primary end point was death from coronary heart disease or nonfatal myocardial infarction at 5 years.RESULTSThe median duration of follow-up was 4.8 years, which yielded 20,254 patient-years of follow-up. The 5-year rate of the primary end point was lower in the CTA group than in the standard-care group (2.3% [48 patients] vs. 3.9% [81 patients]; hazard ratio, 0.59; 95% confidence interval [CI], 0.41 to 0.84; P = 0.004). Although the rates of invasive coronary angiography and coronary revascularization were higher in the CTA group than in the standard-care group in the first few months of follow-up, overall rates were similar at 5 years: invasive coronary angiography was performed in 491 patients in the CTA group and in 502 patients in the standard- care group (hazard ratio, 1.00; 95% CI, 0.88 to 1.13), and coronary revascularization was performed in 279 patients in the CTA group and in 267 in the standard-care group (hazard ratio, 1.07; 95% CI, 0.91 to 1.27). However, more preventive therapies were initiated in patients in the CTA group (odds ratio, 1.40; 95% CI, 1.19 to 1.65), as were more antianginal therapies (odds ratio, 1.27; 95% CI, 1.05 to 1.54). There were no significant between-group differences in the rates of cardiovascular or noncardiovascular deaths or deaths from any cause.CONCLUSIONSIn this trial, the use of CTA in addition to standard care in patients with stable chest pain resulted in a significantly lower rate of death from coronary heart disease or nonfatal myocardial infarction at 5 years than standard care alone, without resulting in a significantly higher rate of coronary angiography or coronary revascularization.