胸痛症状及其联合辅助检查在冠心病诊断中的价值分析

The value of chest pain symptoms and its combination with supplementary examination in the diagnosis of coronary heart disease

目的探讨胸痛症状及其联合辅助检查在冠心病诊断中的价值。方法 9847例入院疑诊冠心病并行冠状动脉造影确诊或排除冠心病的患者,分为有胸痛组8156例和无胸痛组1672例,不能明确有无胸痛病例19例。将除冠状动脉造影外的相关辅助检查分别与胸痛症状构成不同诊断组合,比较不同组合诊断冠心病效率差异。并对冠心病患者不同人群在胸痛特征方面的差异及冠心病患者不同胸痛特征与冠脉病变程度的差异进行研究。结果 (1)冠心病发病率65.2%。胸痛症状联合CT冠状动脉成像诊断冠心病的阳性预测值、阴性预测值、符合度及约登指数均最高(分别为95.1%、43.6%、76.3%及0.560)。胸痛症状联合运动负荷心电图诊断冠心病的特异度及漏诊率均最高(分别为74.9%及89.8%),灵敏度、误诊率、阳性预测值、符合度及约登指数均最低(分别为10.2%、25.1%、36.9%、6.0%及-0.149)。胸痛症状联合负荷核素心肌显像的灵敏度及误诊率均最高(分别为95.7%及98.4%),特异度、漏诊率及阴性预测值均最低(分别为1.6%、4.3%及20.0%)。心电图4种组合中,胸痛症状联合运动负荷心电图诊断冠心病的特异度较高(74.9%),胸痛症状联合除运动负荷心电图外其他心电图检查诊断冠心病的灵敏度均较高。(2)冠心病有胸痛组女性患者比例高于无胸痛组,差异有统计学意义(P<0.05)。无胸痛组的吸烟史比例高于有胸痛组,差异有统计学意义(P<0.05)。(3)胸痛组冠脉病变平均支数、三支病变比例及冠脉病变平均总积分均高于无胸痛组,三组差异无统计学意义(均P<0.05)。结论 (1)负荷核素心肌显像检查是筛查的较好方案。运动负荷心电图检查及CT冠状动脉成像是确诊的较好方案。静息心电图、发作心电图及24h动态心电图是心电图检查中筛查的较好方案。(2)女性冠心病患者更多表现为有胸痛,有吸烟史的患者更多表现为无胸痛。(3)有胸痛患者冠脉病变程度较重。

Objective To evaluate the chest pain symptoms and its combination with supplementary examination in the diagnosis of coronary heart disease （CHD）. Methods Total 9847 cases admitted to hospital with suspected CHD and diagnosed and excluded CHD by coronary angiography were divided into two groups： one was the chest pain group of 8156 cases and the other was non-chest pain group of 1672 cases. Chest pain and different types of supplementary examination（except for coronary angiography） constituted a combination of different diagnoses. We compared different diagnostic efficiency of CHD, studied population heterogeneity of chest pain characteristics in patients with CHD and studied the differences of coronary lesions severity in patients with CHD. Results （1） The prevalence of CHD is 65.2%. Chest pain symptoms combined with coronary CT angiography has the highest positive predictive value, negative predictive value, conformance and Youden index （95.1%, 43.6%, 76.3% and 0.560, respectively）. Chest pain symptoms combined with exercise stress ECG has the highest specificity and false negative rate （74.9 and 89.8%, respectively）, and has the lowest sensitivity, false positive rate, positive predictive value, conformance and Youden index （10.2%, 25.1%, 36.9%, 6.0% and -0.149, respectively）. Chest pain symptoms combined with myocardial perfusion imaging has the highest sensitivity and false negative rate （95.7% and 98.4%, respectively）, and has the lowest specificity, false negative rate and negative predictive value （1.6%, 4.3% and 20.0%, respectively）. Chest pain symptoms combined with exercise stress ECG has higher specificity （74.9%）. Chest pain symptoms combined with ECG has higher specificity （except for exercise stress ECG）. （2） For the female patients with CHD, the proportion of chest pain group is higher than that of non-chest pain group. The difference was statistically significant （P0.05）. For CHD patients who had smoking history, the proportion of the non-chest pain group is higher than that of chest pain group. The difference was statistically significant （P0.05）. （3） Average count of CHD, the proportion of three lesions and the average total score of coronary artery lesions are higher in the chest pain group than in the non-chest pain group （three P0.05）. Conclusions （1） Myocardial perfusion imaging is an acceptable suggestion toward screening CHD. Exercise stress ECG is an acceptable suggestion toward diagnosing CHD. Resting ECG, attack ECG and 24-hour Holter are also an acceptable suggestion toward screening CHD. （2） For female patients with CHD, the proportion of chest pain is higher. For CHD patients who had smoking history, the proportion of non-chest pain is higher. （3） For patients with chest pain caused more severe degree of CHD.