Functional imaging for chest pain in the emergency room: To do or not to do?
Functional imaging for chest pain in the emergency room: To do or not to do?
复制标题
急诊室胸痛的功能成像：做还是不做？
DOI：
10.1007/s12350-015-0225-1
复制
发表时间：
2016
期刊：
影响因子：
--
通讯作者：
Gupta,Himanshu
中科院分区：
文献类型：
--
作者：
Gupta,Himanshu
急诊室胸痛评估是一个重要的临床问题，对患者和社会都有重大的经济影响。冠状动脉疾病（CAD）仍然是急诊室胸痛病因评估的首要鉴别诊断。因此，根据临床怀疑，经常进行一系列测试，包括系列心脏标志物、心电图和成像研究。CAD高危患者通常被认为适合直接进行有创评估，而中低风险患者则接受无创功能评估。功能/应力成像是对患者进行风险分层的重要步骤，并在降低经济成本的同时充当侵入性方法的守门人。1，2核（单光子发射计算机断层扫描，SPECT）应力测试形成了这些研究的主要部分。其他方式，如冠状动脉计算机血管造影术，负荷超声心动图，和负荷心脏磁共振（stress-CMR）也经常用于此类患者队列。每种方法都有其独特的优点和缺点。最近对负荷CMR和负荷SPECT用于评价CAD的诊断准确性进行的荟萃分析发现，两种模式的测试特征相似（尽管负荷CMR的灵敏度略优于SPECT）。3直接比较负荷CMR和SPECT在ER中度风险患者人群中的胸痛评估尚未得到广泛研究。因此，该杂志最近研究的作者应该受到赞扬，因为他们进行了一项设计良好的研究，解决了这一重要问题。4.本研究是在一个因胸痛到急诊室就诊的有中度CAD风险的连续患者队列中进行的。所有患者均使用当代临床方案在短时间内接受了应力CMR和SPECT。那些阳性的研究，无论模态或持续胸痛进行心导管插入术。其余患者的临床随访平均持续时间为2.6±1.1年。他们发现两种方法在识别CAD（定义为心导管插入术期间50%冠状动脉阻塞或临床事件（心源性死亡、心肌梗死[MI]或冠状动脉血运重建的复合事件））方面的敏感性、特异性和诊断准确性相似。值得注意的是，他们没有提供接受冠状动脉造影术的受试者的[70%狭窄]或基于冠状动脉分布的数据。此外，由于并非所有患者都接受了有创冠状动脉造影术，因此无法排除验证偏倚。这些研究结果需要在前瞻性多中心和多供应商前瞻性中进行复制
Chest pain evaluation in the emergency room (ER) is an important clinical problem that has significant economic impact for the patient and the society. Coronary artery disease (CAD) remains the number one differential diagnosis for the etiology of chest pain evaluation in ER. Therefore, based on clinical suspicion, a battery of tests that include serial cardiac markers, ECGs, and imaging studies are frequently performed. Those at high risk of CAD are generally considered appropriate for direct invasive evaluation while intermediate-to low-risk patients undergo non-invasive functional assessment. Functional/stress imaging is an important step to risk stratify the patients and acts as gatekeeper to invasive approach while reducing economic costs. 1, 2 Nuclear (single-photon emission computed tomography, SPECT) stress testing forms the major bulk of these studies. Other modalities such as coronary computed angiography, stress echocardiography, and stress cardiac magnetic resonance (stress-CMR) are also frequently used in such patient cohorts. Each method has its own unique advantages and disadvantages. A recent meta-analysis of the diagnostic accuracy of stress-CMR and stress-SPECT for evaluating CAD found similar test characteristics of the two modalities (although the sensitivity of stress CMR was somewhat better compared to SPECT). 3 Direct comparison of stress CMR and SPECT for chest pain evaluation in ER with intermediate risk patient population has not been extensively studied.Therefore, the authors of the recent study in this journal should be commended for conducting a well-designed study that addresses this important issue. 4 This singlecenter prospective study was performed on a consecutive patient cohort presenting to ER for chest pain with intermediate risk of CAD. All underwent stress-CMR and SPECT within a short duration using contemporary clinical protocols. Those with positive study regardless of modality or persistent chest pain underwent cardiac catheterization. Remaining patients were followed clinically for a mean duration of 2.6±1.1 years. They found similar sensitivity, specificity, and diagnostic accuracy for identifying CAD defined as [50% coronary blockage during cardiac catheterization or clinical event (composite of cardiac death, myocardial infarction [MI], or coronary revascularization), for the two modalities. Of note, they did not provide data for [70% stenosis or based on coronary artery distribution for participants who underwent coronary angiography. Furthermore, since not all patients underwent invasive coronary angiography, verification bias cannot be excluded. These study results need replication in a prospective multi-center and multi-vendor prospective