CT-血流储备分数指导稳定性冠心病患者的治疗观察

CT-fractional flow reserve guided the management in patients with stable coronary heart disease

目的探讨CT-冠状动脉血流储备分数(CT-FFR)对稳定性冠心病患者治疗决策的影响。方法该研究收集2019年2月至2021年6月在郑州大学第二附属医院门诊或住院的稳定性冠状动脉疾病患者CTA和CT-FFR的结果,以指导中度狭窄(30%~75%)患者的治疗决策。收集CTA数据,并用FFR软件分析血流储备分数数据,定义病变远端冠状动脉管腔直径2 mm处CT-FFR值≤0.8为显著狭窄具有血流动力学意义。根据CTA及CT-FFR结果将患者分为4组,A组:CTA狭窄<50%,采用最佳药物治疗;B组:CTA狭窄≥50%且CT-FFR>0.80,采用最佳药物治疗;C组:CTA狭窄≥50%且CT-FFR≤0.80,采用最佳药物治疗;D组:CTA狭窄≥50%且CT-FFR≤0.80,采用最佳药物治疗及有创冠状动脉造影术,必要时行支架植入或者冠脉搭桥手术。对患者进行为期1年的随访,观察主要不良心血管事件的发生率。各组间采用检验进行比较;组间平均值用t检验,两个以上组间平均数比较用Kruskal Wallis检验;使用Kaplan-Meier方法评估复合终点风险率比例。结果(1)本研究共纳入330例患者,其中一支或者多支冠脉血管处于中度狭窄(30%~75%)的136例患者并进行CT-FFR分析;(2)136例CT-FFR分析结果中,23例患者(17%)的检测结果为狭窄<50%;35名患者(26%)的CTA检测结果为狭窄≥50%但为阴性(CT-FFR>0.8);78例患者的检测结果为狭窄≥50%且为阳性(CT-FFR≤0.80),其中34名患者单接受最佳药物治疗;(3)随访结束时,A组和B组主要不良心血管事件发生率相似(23%比29%),但与A组比较,C组和D组主要不良心血管事件发生率比例明显升高(分别为65%、32%)。重要的是D组(14%)非致命性心肌梗死的发生率明显低于C组(32%,P<0.05)的。结论在中度狭窄的稳定性冠状动脉疾病患者中,CT-FFR可有效地识别不需要进一步诊断检测或介入干预的患者(CT-FFR>0.80)和需要进一步有创冠脉造影检测和介入干预的高危患者(CT-FFR≤0.80)。CT-FFR能够评估患者的风险和为患者治疗提供最佳策略指导。

Objective To explore the influence of CT-coronary flow reserve fraction on treatment decision-making in patients with stable coronary heart disease.Methods The results of CTA and CT-FFR assessments were collected from patients with stable coronary artery disease who were admitted or admitted to our hospital between February 2019 and June 2021 to guide treatment decisions in patients with moderate stenosis(30%-75%).Spiral CT was used to collect CTA data,and CT-FFR software was used to analyze the flow reserve fraction data.CT-FFR value≤0.8 of the distal coronary lumen with a diameter of 2 mm was defined as significant stenosis with hemodynamic significance.According to the results of CTA and CT-FFR,the patients were divided into 4 groups,A group:CTA stenosis<50%,optimal medical treatment;B group:CTA stenosis≥50% and CT-FFR>0.80,optimal medical treatment;C group:CTA stenosis≥50% and CT-FFR≤0.80,optimal medical treatment;D group:CTA stenosis≥50% and CT-FFR≤0.80,optimal medical treatment and invasive coronary angiography were used,and stenting,balloon dilation or coronary artery bypass surgery was performed if necessary.Patients were followed for 1 years to observe the incidence of major adverse cardiovascular events(all-cause death,non-fatal myocardial infarction,hospitalization with unstable angina,and unplanned revascularization).Results(1)A total of 330 patients were included in this study,among which 136 patients with one or more coronary vessels with moderate stenosis(30%-75%)were analyzed by CT-FFR.A total of 194 patients were excluded from the study because of severe or substandard coronary artery stenosis,stent implantation or pacemaker implantation before coronary CTA examination,severe artifacts and noise of images,and severe coronary artery calcification.(2)CT-FFR analysis was performed successfully in 136 patients with CTA results,and stenosis<50%was detected in 23 patients(17%).A total of 35 patients(26%)had stenosis≥50% but negative CTA results(CT-FFR>0.8);A total of 78 patients had stenosis≥50% and the results were positive(CT-FFR≤0.80),and 34 of them received only optimal medical treatment.(3)At the end of follow-up,A group and B group had similar rates of major adverse cardiovascular events(23%vs.29%),but C group and D group had significantly increased rates of major adverse cardiovascular events(65%and 32%,respectively)compared to group A.Importantly,the incidence of non-fatal myocardial infarction was significantly lower in D group(14%)than in C group(32%,P<0.05).Conclusion In patients with stable coronary artery disease with moderate stenosis,CT-FFR can effectively identify patients who do not require further diagnostic testing or intervention(CT-FFR>0.80)and high-risk patients who require further invasive coronary angiography and intervention(CT-FFR≤0.80).CT-FFR can assess patients’risk and provide optimal strategic guidance for patients.