动态^(99m)Tc-sestamibi CZT-SPECT评价老年胸痛患者冠状动脉微血管功能障碍的临床特征

Assessment of clinical characteristics of coronary microvascular dysfunction in elderly patients with chest pain by dynamic ^(99m)Tc-sestamibi CZT-SPECT camera

目的冠状动脉微血管功能障碍(coronary microvascular dysfunction,CMVD)常介导非内皮依赖性微血管的异常扩张,引起缺血和心绞痛。对于无心外膜冠状动脉狭窄的心血管疾病,微血管病变起着非常重要的作用,并与心血管事件的增加有关。冠状动脉血流储备(coronary flow reserve,CFR)是微血管水平检测冠状动脉硬化早期征象的最敏感参数之一。新型动态^(99m)Tc-sestamibi CZT-SPECT评估CFR已成为检测CMVD的一种很有希望的技术。我们旨在通过冠状动脉造影和动态CZT-SPECT描述胸痛患者CMVD的患病率、临床特征和预后。方法入选2020年1月至2022年1月因胸痛在华东医院住院的老年(年龄≥60岁患者298例)。他们均接受了冠状动脉造影和动态/常规状态下静息/负荷门控心肌灌注显像(myocardial perfusion imaging,MPI)。在血管水平上,如果任何冠状动脉狭窄<50%且CFR<2,则认为是CMVD。在患者层面,CMVD被认为是非阻塞性冠心病(coronary artery disease,CAD)的一种。我们还收集了病史、生化指标等信息。随访至2023年6月30日。主要不良心血管事件(major adverse cardiovascular event,MACE)定义为:因胸闷胸痛再住院、急性冠脉综合征和死亡。结果73.5%的患者有心绞痛但冠脉造影阴性。30.9%非阻塞性CAD患者有CMVD。非阻塞性CAD中,CFR<2组MACE发生率较CFR≥2组高(P<0.001)。在Logistic回归分析中,发现糖尿病(β1.837,OR 6.227,95%CI 3.07112.831,P<0.001)、冠状动脉慢血流(coronary slow flow,CSF)(β1.150,OR 3.157,95%CI 1.3417.434,P=0.009)和高脂血症(β0.832,OR 2.297,95%CI 1.0525.016,P=0.037)为CMVD的重要预测因子。结论在非阻塞性CAD患者中CMVD的MACE发生率高。糖尿病、高脂血症和CSF是CMVD的独立预测因子。采用动态^(99m)Tc-sestamibi CZT-SPECT定量CFR检测在技术上是可行的,可以反映冠状动脉微血管功能。

Objective Coronary microvascular dysfunction(CMVD)often mediates abnormal expansion of non-endothelial dependent microvessels and causes ischemia and angina pectoris.For cardiovascular diseases without epicardial coronary artery stenosis,microvascular lesions play a very important role and are related to the increase in cardiovascular events.Coronary flow reserve(CFR)is one of the most sensitive parameters to detect the early signs of coronary atherosclerosis at the microvascular level.The new dynamic ^(99m)Tc-sestamibi CZT-SPECT for evaluating CFR has emerged as a promising technique for determination of CMVD.We aimed to describe the prevalence,clinical features,and prognosis of CMVD in patients with chest pain by coronary angiography and dynamic CZT-SPECT.Methods A total of 298 elderly patients(aged≥60 years)who were hospitalized in Huadong Hospital due to chest pain from January 2020 to January 2022 were selected.They all underwent coronary angiography and rest/stress dynamic and routine gated myocardial perfusion imaging(MPI).At the vascular level,if any coronary artery stenosis<50%and CFR<2,it was considered CMVD.At the patient level,CMVD was considered a type of non-obstructive coronary artery disease(CAD).The medical history,biochemical indicators,and other information of the patients were collected.The follow-up was conducted until June.30,2023.The major adverse cardiovascular event(MACE)was defined as readmission due to chest tightness and pain,acute coronary syndrome(ACS)and death.Results 73.5%of the patients had angina,but their coronary angiography was negative.30.9%of patients with non-obstructive CAD had CMVD.In non-obstructive CAD patients,the incidence of MACE in the CFR<2 group was higher than that in the CFR≥2 group(P<0.001).Logistic regression analysis found that diabetes(β1.837,OR 6.227,95%CI 3.071-12.831,P<0.001),coronary slow flow(CSF)(β1.150,OR 3.157,95%CI 1.341-7.434,P=0.009)and hyperlipidemia(β0.832,OR 2.297,95%CI 1.052-5.016,P=0.037)were important predictors of CMVD.Conclusion Among non-obstructive CAD patients,CMVD patients have a higher incidence of MACE.Diabetes,hyperlipidemia and CSF are independent predictors of CMVD.Quantitative CFR detection by dynamic 99m Tc-sestamibi CZT-SPECT is technically feasible and can reflect coronary microvascular function.