Integrated Noninvasive Physiological Assessment of Coronary Circulatory Function and Impact on Cardiovascular Mortality in Patients With Stable Coronary Artery Disease.
Integrated Noninvasive Physiological Assessment of Coronary Circulatory Function and Impact on Cardiovascular Mortality in Patients With Stable Coronary Artery Disease.
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DOI：
10.1161/circulationaha.117.029992
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发表时间：
2017-12-12
期刊：
影响因子：
37.8
通讯作者：
Di Carli MF
中科院分区：
文献类型：
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作者：
Gupta A;Taqueti VR;van de Hoef TP;Bajaj NS;Bravo PE;Murthy VL;Osborne MT;Seidelmann SB;Vita T;Bibbo CF;Harrington M;Hainer J;Rimoldi O;Dorbala S;Bhatt DL;Blankstein R;Camici PG;Di Carli MF
最大心肌血流量（MBF）和冠状动脉血流储备（CFR）的整合，称为冠状动脉血流容量，可以全面评估已知或怀疑稳定性冠状动脉疾病的患者。由于管理决策取决于临床风险，我们试图确定最大MBF和CFR预测心血管死亡的独立和综合价值。从2006年1月至2013年12月，对4,029例连续患者（中位年龄66岁，50.5%为女性）进行了静息/负荷心肌灌注正电子发射断层扫描，对MBF和CFR进行了定量。主要结局为心血管死亡率。最大MBF<1.8ml·g-1·min-1和CFR<2为受损。根据最大MBF或CFR的一致或不一致损害确定了四个患者组。采用考克斯和泊松回归分析评估最大MBF和CFR与心血管死亡的相关性。在中位随访5.6年期间，共发生392例（9.7%）心血管死亡。CFR是一个比最大MBF更强的心血管死亡预测因子，超出了传统的心血管危险因素，左心室射血分数，心肌瘢痕和缺血，心率-压力乘积，放射性示踪剂或应激剂的类型，以及扫描后血运重建（调整后的风险比，HR [95%置信区间，CI]：1.79 [1.38-2.31]，校正最大MBF和临床协变量后，CFR每单位降低p<0.001，和1.03 [0.84-1.27]，校正CFR和临床协变量后，最大MBF每单位降低p=0.8）。在单变量分析中，CFR和最大MBF受损一致的患者每年心血管死亡率高3.3%（95%CI：2.9-3.7%）。CFR受损但保留最大MBF的患者每年的心血管死亡率为1.7%（95% CI：1.3-2.1%）;这些患者主要是女性（70%）。CFR保留但最大MBF受损的患者的心血管死亡率较低，为每年0.9%（95% CI：0.6-1.6%）。CFR和最大MBF保持一致的患者的心血管死亡率最低，为每年0.4%（95%CI：0.3-0.6%）。在多变量分析中，四个一致或不一致类别的心血管死亡风险梯度由CFR受损独立驱动，与最大MBF受损无关。CFR比最大MBF更能预测心血管死亡率。基于CFR和最大MBF的整合的一致和不一致分类识别已知或疑似冠状动脉疾病患者的独特预后表型。
It is suggested that the integration of maximal myocardial blood flow (MBF) and coronary flow reserve (CFR), termed coronary flow capacity, allows comprehensive evaluation of patients with known or suspected stable coronary artery disease. As management decisions are predicated on clinical risk, we sought to determine the independent and integrated value of maximal MBF and CFR for predicting cardiovascular death. MBF and CFR were quantified in 4,029 consecutive patients (median age 66 years, 50.5% women) referred for rest/stress myocardial perfusion positron emission tomography scans from January 2006 to December 2013. The primary outcome was cardiovascular mortality. Maximal MBF<1.8 ml·g-1·min-1 and CFR<2 were considered impaired. Four patient groups were identified based on the concordant or discordant impairment of maximal MBF or CFR. Association of maximal MBF and CFR with cardiovascular death was assessed using Cox and Poisson regression analyses. A total of 392 (9.7%) cardiovascular deaths occurred over a median follow-up of 5.6 years. CFR was a stronger predictor of cardiovascular mortality than maximal MBF beyond traditional cardiovascular risk factors, left ventricular ejection fraction, myocardial scar and ischemia, rate-pressure-product, type of radiotracer or stress agent used, and revascularization post-scan (adjusted Hazard Ratio, HR [95% Confidence-Interval, CI]: 1.79 [1.38-2.31], p<0.001 per unit decrease in CFR after adjustment for maximal MBF and clinical covariates, and 1.03 [0.84-1.27], p=0.8 per unit decrease in maximal MBF after adjustment for CFR and clinical covariates). In univariable analyses, patients with concordant impairment of CFR and maximal MBF had high cardiovascular mortality of 3.3% (95%CI: 2.9-3.7%) per year. Patients with impaired CFR but preserved maximal MBF had an intermediate cardiovascular mortality of 1.7% (95% CI: 1.3-2.1%) per year; these patients were predominantly women (70%). Patients with preserved CFR but impaired maximal MBF had low cardiovascular mortality of 0.9% (95% CI: 0.6-1.6%) per year. Patients with concordantly preserved CFR and maximal MBF had the lowest cardiovascular mortality of 0.4% (95% CI: 0.3-0.6%) per year. In multivariable analysis, the cardiovascular mortality risk gradient across the four concordant or discordant categories was independently driven by impaired CFR irrespective of impairment in maximal MBF. CFR is a stronger predictor of cardiovascular mortality than maximal MBF. Concordant and discordant categories based on integrating CFR and maximal MBF identify unique prognostic phenotypes of patients with known or suspected coronary artery disease.