Low diagnostic yield of elective coronary angiography.
Low diagnostic yield of elective coronary angiography.
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DOI：
10.1056/nejmoa0907272
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发表时间：
2010-03-11
期刊：
影响因子：
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通讯作者：
Douglas PS
中科院分区：
文献类型：
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作者：
Patel MR;Peterson ED;Dai D;Brennan JM;Redberg RF;Anderson HV;Brindis RG;Douglas PS
心导管术患者分类指南建议进行风险评估和无创检测。我们确定了当代国家样本中疑似冠心病患者的无创检测模式和导管插入术的诊断率。从2004年1月到2008年4月，在美国心脏病学会国家心血管数据登记处的663家医院，我们确定了接受择期导管插入术的无已知冠状动脉疾病的患者。患者的人口统计学特征、危险因素、症状和无创检查结果与阻塞性冠状动脉疾病的存在相关，阻塞性冠状动脉疾病定义为左主干冠状动脉直径的50%或以上狭窄或主要心外膜血管直径的70%或以上狭窄。共有398，978例患者入选本研究。中位年龄为61岁; 52.7%的患者为男性，26.0%患有糖尿病，69.6%患有高血压。在83.9%的患者中进行了非侵入性检测。在导管插入时，149，739名患者（37.6%）患有阻塞性冠状动脉疾病。39.2%的患者未报告冠状动脉疾病（定义为所有血管狭窄<20%）。阻塞性冠状动脉疾病的独立预测因素包括男性（比值比，2.70; 95%置信区间[CI]，2.64至2.76），老年（每5年增量的比值比，1.29; 95% CI，1.28 - 1.30），存在胰岛素依赖型糖尿病（比值比，2.14; 95%CI，2.07至2.21），以及存在血脂异常（比值比，1.62; 95%CI，1.57至1.67）。非侵入性检查结果阳性的患者比未接受任何检查的患者更容易患阻塞性冠状动脉疾病（41.0% vs. 35.0%; P<0.001;校正比值比，1.28; 95%CI，1.19 - 1.37）。在这项研究中，略多于三分之一的没有已知疾病的患者接受了选择性心导管插入术，患有阻塞性冠状动脉疾病。在常规临床实践中，需要更好的风险分层策略来告知决策并增加心导管插入术的诊断率。
Guidelines for triaging patients for cardiac catheterization recommend a risk assessment and noninvasive testing. We determined patterns of noninvasive testing and the diagnostic yield of catheterization among patients with suspected coronary artery disease in a contemporary national sample. From January 2004 through April 2008, at 663 hospitals in the American College of Cardiology National Cardiovascular Data Registry, we identified patients without known coronary artery disease who were undergoing elective catheterization. The patients’ demographic characteristics, risk factors, and symptoms and the results of noninvasive testing were correlated with the presence of obstructive coronary artery disease, which was defined as stenosis of 50% or more of the diameter of the left main coronary artery or stenosis of 70% or more of the diameter of a major epicardial vessel. A total of 398,978 patients were included in the study. The median age was 61 years; 52.7% of the patients were men, 26.0% had diabetes, and 69.6% had hypertension. Noninvasive testing was performed in 83.9% of the patients. At catheterization, 149,739 patients (37.6%) had obstructive coronary artery disease. No coronary artery disease (defined as <20% stenosis in all vessels) was reported in 39.2% of the patients. Independent predictors of obstructive coronary artery disease included male sex (odds ratio, 2.70; 95% confidence interval [CI], 2.64 to 2.76), older age (odds ratio per 5-year increment, 1.29; 95% CI, 1.28 to 1.30), presence of insulin-dependent diabetes (odds ratio, 2.14; 95% CI, 2.07 to 2.21), and presence of dyslipidemia (odds ratio, 1.62; 95% CI, 1.57 to 1.67). Patients with a positive result on a noninvasive test were moderately more likely to have obstructive coronary artery disease than those who did not undergo any testing (41.0% vs. 35.0%; P<0.001; adjusted odds ratio, 1.28; 95% CI, 1.19 to 1.37). In this study, slightly more than one third of patients without known disease who underwent elective cardiac catheterization had obstructive coronary artery disease. Better strategies for risk stratification are needed to inform decisions and to increase the diagnostic yield of cardiac catheterization in routine clinical practice.