Troponin-positive chest pain with unobstructed coronary arteries: incremental diagnostic value of cardiovascular magnetic resonance imaging
Troponin-positive chest pain with unobstructed coronary arteries: incremental diagnostic value of cardiovascular magnetic resonance imaging
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DOI：
10.1093/ehjci/jev289
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发表时间：
2016-10-01
影响因子：
6.2
通讯作者：
Selvanayagam, Joseph B.
中科院分区：
文献类型：
--
作者：
Pathik, Bhupesh;Raman, Betty;Selvanayagam, Joseph B.
目的：肌钙蛋白阳性的胸痛患者冠状动脉通畅是一个临床难题。心血管磁共振（CMR）成像在这些患者的评估中发挥着越来越重要的作用;然而，除了专家临床判断外，其效用尚不清楚。我们试图确定CMR的增量诊断价值以及经验丰富的心脏病专家在提供该人群的盲态临床和研究数据时诊断的异质性。方法和结果2010年至2014年期间，共有125名连续患者因心源性胸痛、肌钙蛋白升高和心肌梗死而前往三级中心。（>29 ng/L），并且无阻塞的冠状动脉被招募并进行CMR。一个由三名经验丰富的心脏病专家组成的小组，他们不知道CMR的诊断，也不知道对方的评估，他们根据临床和调查结果提供了诊断。共识小组诊断定义为两名或更多心脏病专家共享相同的临床诊断。结果分为急性心肌炎、Takotsubo心肌病、急性心肌梗死（AMI）或不确定。CMR在87%的患者中提供了诊断。在65/125例（52%）患者中，共识组诊断和CMR一致。3位心脏病专家的一致性为中等水平（k = 0.47，P < 0.05），而共识组与CMR的一致性较差（k = 0.38，P < 0.05），以CMR诊断的AMI患者的不一致性最高。CMR与临床诊断的一致性较差。CMR为大多数此类患者提供了诊断。
Aims Troponin-positive chest pain patients with unobstructed coronaries represent a clinical dilemma. Cardiovascular magnetic resonance (CMR) imaging has an increasingly prominent role in the assessment of these patients; however, its utility in addition to expert clinical judgement is unclear. We sought to determine the incremental diagnostic value of CMR and the heterogeneity in diagnoses by experienced cardiologists when presented with blinded clinical and investigative data in this population.Methods and results A total of 125 consecutive patients presenting to a tertiary centre between 2010 and 2014 with cardiac chest pain, elevated troponin (>29 ng/L), and unobstructed coronaries were enrolled and underwent CMR. A panel of three experienced cardiologists unaware of the CMR diagnosis and blinded to each other's assessment provided a diagnosis based on clinical and investigative findings. A consensus panel diagnosis was defined as two or more cardiologists sharing the same clinical diagnosis. Findings were classified into acute myocarditis, Takotsubo cardiomyopathy, acute myocardial infarction (AMI), or indeterminate. CMR provided a diagnosis in 87% of patients. Consensus panel diagnosis and CMR were concordant in 65/125 (52%) patients. There was an only moderate level of agreement between the three cardiologists (k = 0.47, P < 0.05) and a poor level of agreement between the consensus panel and CMR (k = 0.38, P < 0.05) with the most disagreement seen in patients with AMI diagnosed on CMR.Conclusion The clinical diagnosis of patients with non-obstructive coronaries and positive troponin remains a challenge. The concordance between CMR and clinical diagnosis is poor. CMR provides a diagnosis in majority of these patients.