CT血流储备分数与冠状动脉周围脂肪衰减指数联合临床及冠状动脉CT血管造影特征预测主动脉瓣置换术术后不良心血管事件

目的 评估CT血流储备分数(CT-FFR)与冠状动脉周围脂肪衰减指数(FAI)联合临床及冠状动脉CT血管造影(CCTA)特征预测主动脉瓣置换术(AVR)术后发生主要不良心血管事件(MACE)的价值。方法 回顾性分析139例接受AVR的主动脉瓣狭窄患者,根据随访中是否发生MACE将其分为MACE组与非MACE组;以Cox比例风险回归分析临床、CCTA及冠状动脉CT-FFR、FAI,筛选术后发生MACE的独立预测因素,基于临床、CCTA特征,以及CT-FFR及右冠状动脉(RCA)FAI建立嵌套模型。绘制受试者工作特征(ROC)曲线,计算曲线下面积(AUC)及Harrell C指数,评估各模型诊断效能及其拟合优度。结果 MACE组22例、无MACE组117例。CT-FFR(HR=3.683)及RCA-FAI(HR=3.261)均为AVR术后发生MACE的独立预测因素。临床模型、临床+CCTA、临床+CCTA+CT-FFR模型及临床+CCTA+CT-FFR+RCA-FAI模型预测AVR术后MACE的AUC分别为0.636、0.730、0.758及0.817,C指数分别为0.614、0.707、0.733及0.782;其中,临床+CCTA+CT-FFR+RCA-FAI模型预测结果与实际结果的一致性最高、拟合优度最佳。结论 CT-FFR及RCA-FAI联合临床及CCTA特征能有效预测AVR术后MACE。     

冠状动脉周围脂肪参数联合临床指标预测急性冠状动脉综合征主要不良心血管事件

目的 探讨冠状动脉周围脂肪组织(PCAT)脂肪衰减指数(FAI)联合临床指标预测急性冠状动脉综合征(ACS)患者发生主要不良心血管事件(MACE)的价值。方法 回顾性分析186例首诊ACS患者,根据随访发生MACE与否将其分为MACE组和无MACE组。采用单因素分析和多因素logistic 回归分析临床资料、实验室指标及冠状动脉CT血管造影(CCTA)所示冠状动脉主要分支左前降支(LAD)、左旋支(LCX)、右冠状动脉(RCA)狭窄程度、斑块性质及PCAT体积和FAI,筛选ACS发生MACE的独立预测因素;绘制受试者工作特征(ROC)曲线,计算曲线下面积(AUC),评价单一独立预测因素及其联合的预测效能。结果 MACE组35例,无MACE组151例。RCA-FAI(OR=0.127)及高密度脂蛋白胆固醇(HDL)(OR=1.098)是ACS MACE的独立预测因素(P均＜0.05)。以RCA-FAI预测ACS MACE的AUC为0.671,HDL的AUC为0.371,二者联合AUC为0.709。结论 RCA-FAI联合HDL可用于预测ACS患者发生MACE。     

改良单次短时屏气法用于血管减影冠状动脉CT成像

目的 观察改良单次短时屏气法用于血管减影冠状动脉CT成像（S-CCTA）的价值。方法 收集21例冠状动脉钙化复查（n=18）或冠状动脉支架植入术后（n=3）患者,采用改良单次短时屏气法行S-CCTA扫描,获得两次扫描图像和减影后图像后进行处理,采用4分制评价冠状动脉CT血管成像（CCTA）及S-CCTA图像质量,观察以严重钙化节段评估管腔狭窄程度的能力,并计算有效辐射剂量（ED）。结果 21例患者屏气时间为（10.34±1.07）s,辐射ED为（3.43±1.04）mSv。18例冠状动脉钙化复查患者共90个钙化斑块,S-CCTA图像质量[（3.47±0.69）分]明显高于CCTA[（2.48±0.70）分,P<0.001）,且S-CCTA图像所示可用于评估管腔狭窄程度的严重钙化冠状动脉节段（88.89%）明显多于CCTA图像（66.67%,P<0.001）;3例冠状动脉支架植入术后患者共植入5枚支架,其S-CCTA图像质量[（2.75±0.29）分]明显高于CCTA[（1.84±0.23）分,P<0.05]。结论 改良单次短时屏气S-CCTA可有效缩短屏气时间、减少辐射剂量并提高冠状动脉图像质量。     

冠状动脉CTA斑块特征评价支架内再狭窄风险

目的 探讨冠状动脉CTA斑块特征评估植入支架后发生支架内再狭窄（ISR）的风险。方法 对166例患者于支架植入前行冠状动脉CTA检查,观察血管狭窄程度和斑块特征,并于植入支架后6~18个月内复查冠状动脉造影;根据有无ISR,将其分为ISR组（n=16）与无ISR组（n=150）,比较两组间的差异;采用多因素Logistic回归分析获得ISR的危险因素,以ROC曲线评价各因素诊断ISR的效能。结果 ISR组病变长度,非钙化斑块、点状钙化、正性重构比例和正性重构指数均大于无ISR组（P均<0.05）。多因素Logistic回归分析结果显示,非钙化斑块[回归系数（B）=1.89,优势比（OR）=6.63,P=0.01]、点状钙化（B=1.28,OR=3.59,P=0.01）、正性重构（B=2.17,OR=8.71,P<0.01）、病变长度（B=0.05,OR=1.05,P=0.04）是导致ISR的危险因素。病变长度及正性重构指数诊断ISR的ROC曲线下面积（AUC）分别为0.70和0.82（P均<0.01）,联合上述斑块特征预判ISR的AUC为0.87（P<0.01）。结论 病变长度、正性重构、非钙化斑块、点状钙化可用于评估冠状动脉支架植入后发生ISR的风险。     

多层螺旋CT评价主动脉瓣钙化与冠状动脉斑块性质相关性研究

目的 探讨256层iCT评价主动脉瓣钙化（AVC）与冠状动脉斑块性质的相关性。方法 收集可疑冠状动脉性心脏病患者223例,行冠状动脉CTA（CCTA）。根据有无AVC将患者分为AVC组（n=55）和对照组（n=168）,将冠状动脉斑块分为钙化斑块（CP）、非钙化斑块（NCP）、混合斑块（MP）,并进行统计学分析。结果 AVC组与对照组CP、MP检出率、严重狭窄发生率、冠状动脉钙化积分和冠状动脉病变节段数的差异均有统计学意义（P均<0.05）,而NCP检出率和多支血管病变发生率差异均无统计学意义（P均>0.05）。Logistic回归分析显示AVC与CP、MP、多支病变和严重狭窄的发生均存在独立相关性（OR=3.53、3.51、3.13、5.80,95%CI:1.66~7.50、1.59~7.79、1.45~6.77、2.30~14.60,P均<0.05）,而与NCP的发生无相关性（P>0.05）。结论 AVC与冠状动脉CP和MP的发生独立相关,且AVC的出现多提示冠状动脉病变累及范围更广、更严重。     

冠状动脉CTA观察HIV感染者冠状动脉易损斑块

目的 观察HIV感染者冠状动脉易损斑块是否与非HIV感染者存在差异，分析相关危险因素。方法 对167例HIV感染者（HIV感染组）及185例非感染者（非感染组）行冠状动脉CTA（CCTA），将存在≥2种高危形态学特征的斑块定义为易损斑块，对比分析2组患者冠状动脉易损斑块的类型、位置、发生率，以及HIV感染者冠状动脉易损斑块的相关危险因素。结果 2组患者基线临床资料无明显差异。2组最常见易损斑块类型均为低衰减斑块+正性重构，多位于前降支近段（S6）；HIV组≥1个冠状动脉节段出现易损斑块的发生率较非HIV组增加（34.73% vs 24.32%，P<0.05）。HIV组冠状动脉易损斑块与抗逆转录病毒治疗（ART）药物治疗时间独立相关[OR=1.29，95%CI（1.04，1.59），P=0.02]。结论 HIV感染者冠状动脉易损斑块发生率较非感染者增加；ART药物治疗可能是HIV感染者出现冠状动脉易损斑块的独立危险因素。     

管腔内对比度衰减梯度和改良校正的管腔内对比度衰减梯度分级诊断冠状动脉狭窄

目的 观察管腔内对比度衰减梯度（TAG）和改良校正的管腔内对比度衰减梯度（MTAG-CCO）分级诊断冠状动脉狭窄的价值。方法 回顾性分析133例（302支狭窄血管）冠状动脉狭窄患者（狭窄组）和53例（130支血管）无冠状动脉狭窄患者（对照组）的冠状动脉CTA （CCTA）资料。对狭窄组行冠状动脉造影,并将其分为5个亚组：1级亚组,狭窄程度<25%;2级亚组,25%≤狭窄程度<49%;3级亚组,49%≤狭窄程度<69%;4级亚组,69%≤狭窄程度<99%;5级亚组,狭窄程度≥99%。测量并比较组间及亚组间TAG、MTAG-CCO值。结果 狭窄组TAG值[-（18.20±7.42） HU/10 mm]低于对照组[-（12.39±4.40） HU/10 mm;Z=9 389.00,P<0.001],MTAG-CCO值[-（0.027±0.011）/10 mm]亦低于对照组[-（0.014±0.005）/10 mm;Z=4 555.50,P<0.001]。狭窄组各亚组TAG及MTAG-CCO值与对照组比较差异均有统计学意义（P均<0.05）。1级、2级亚组TAG值高于4级、5级亚组（P均<0.05）。1级、2级亚组MTAG-CCO值高于3级、4级、5级亚组,3级亚组MTAG-CCO值高于5级亚组（P均<0.05）,其余亚组间TAG及MTAG-CCO值差异均无统计学意义（P均>0.05）。结论 TAG及MTAG-CCO均有助于分级诊断冠状动脉狭窄。     

冠状动脉CTA对冠状动脉粥样硬化性心脏病高危人群的随访观察价值

目的 探讨冠状动脉CT血管成像（CCTA）对冠状动脉粥样硬化性心脏病（简称冠心病）高危险因素人群（简称高危人群）的随访观察价值。方法 选取于我院接受CCTA检查且空腹血糖、血脂（甘油三酯、总胆固醇、高密度脂蛋白及低密度脂蛋白）等生化指标及体质量指数有2项或2项以上异常的80例患者,经临床干预后,间隔2年再次行CCTA检查,同时行上述生化指标及体质量指数检测,根据两次CCTA检查结果分为稳定组和进展组,并对2组两次生化指标、体质量指数及其变化率进行统计学分析。结果 稳定组60例,进展组20例。进展组第1次与第2次检查高密度脂蛋白水平差异有统计学意义（t=2.64,P=0.02）;稳定组第2次检查体质量指数、血糖、甘油三酯、总胆固醇及低密度脂蛋白明显小于第1次检查（t=2.10、2.68、3.45、4.26、5.90,P=0.04、0.01、0.001、0.000 1、0.000 1）;进展组第2次检查甘油三酯（t=2.39,P=0.02）和低密度脂蛋白高于稳定组第2次检查（t=3.98,P<0.000 1）;进展组血糖变化率高于稳定组（t=-2.04,P=0.045）。结论 CCTA对于随访观察高危人群冠心病有积极的指导意义,通过加强对冠心病危险因素的积极干预,改变不良生活习惯,可以有效延缓或阻止冠心病的发生及发展。     

CT血流储备分数对心肌缺血病变的诊断效能研究

目的 以导管测量血流储备分数（FFR）为金标准，评价基于血流动力学优化融合模型的CT血流储备分数（CT-FFR）对冠状动脉狭窄所致心肌缺血病变的诊断效能。方法 前瞻性选择127例接受冠状动脉CT血管成像（CCTA）、1周内冠状动脉造影及经导管FFR测量患者（152支血管），以CCTA观察病变狭窄程度，计算CT-FFR。以FFR<0.8为判断心肌缺血金标准，绘制CT-FFR及CCTA的ROC曲线，获得AUC。计算两种方法诊断心肌缺血的敏感度、特异度、阳性预测值、阴性预测值及准确率。结果 CT-FFR与导管测量FFR一致性良好，仅6.6%测量值在95%一致性界限之外。CT-FFR诊断心肌缺血AUC在患者水平（0.92 vs 0.69，P<0.001）和血管水平（0.93 vs 0.69，P<0.001）均优于CCTA。以患者水平CT-FFR<0.8诊断心肌缺血的敏感度、特异度和准确率分别为84.1%、90.6%和85.8%，CCTA>50%分别为82.5%、54.7%和68.5%；血管水平CT-FFR<0.8分别为88.0%、84.7%和84.9%，CCTA>50%分别为80.6%、57.7%和69.1%。CT-FFR对于血管水平狭窄程度30%~70%病变诊断效能仍佳。结论 CT-FFR对心肌缺血病变的诊断效能优于CCTA，有助于临床筛查心肌缺血病变。     

斑点追踪技术评估冠状动脉心脏病患者冠状动脉狭窄程度

目的 观察斑点追踪成像（STI）技术评价冠状动脉心脏病患者冠状动脉狭窄严重程度的价值。方法 对74例拟诊冠状动脉心脏病患者[冠状动脉狭窄组（n=59）和冠状动脉无狭窄组（n=15）]行常规超声和STI技术检查。根据冠状动脉Gensini评分将冠状动脉狭窄组分为轻、中、重度狭窄3个亚组。测量左心室整体平均纵向应变（GLS-Avg）、基底段平均纵向应变（GLS-Bas）、中间段平均纵向应变（GLS-Mid）及心尖段平均纵向应变（GLS-AP）,比较两组间及3个亚组间的差异。结果 冠状动脉狭窄组GLS-Avg、GLS-Bas、GLS-Mid及GLS-AP均低于冠状动脉无狭窄组（P均<0.001）。冠状动脉狭窄组中,随着冠状动脉狭窄程度增加,GLS-Avg、GLS-Bas、GLS-Mid、GLS-AP降低,轻、中、重度狭窄亚组间两两比较差异均有统计学意义（P均<0.05）。冠状动脉狭窄组GLS-Avg、GLS-Bas、GLS-Mid及GLS-AP与Gensini评分均呈正相关（r=0.861、0.847、0.819、0.778,P均<0.05）。结论 采用STI技术获得的左心室整体纵向应变值可在一定程度上反映冠状动脉心脏病患者冠状动脉狭窄程度。     

The prognostic value of multidetector coronary CT angiography for the prediction of major adverse cardiovascular events: a multicenter observational cohort study

To assess the prognostic value of coronary artery stenosis identification by coronary computed tomographic angiography (CCTA) for the prediction of major adverse cardiac events (MACE) in a multicenter prospective cohort study. We performed a prospective multicenter observational cohort study of symptomatic patients with suspected or known coronary artery disease (CAD) (n = 172; 57% male) undergoing CCTA in accordance to ACC/AHA Appropriateness Criteria from 4 sites in and around Paris, France, and followed for a mean duration of 22.0 ± 4.5 months (interquartile range 18–26 months). Coronary arteries by CCTA were interpreted by physicians blinded to the patient characteristics for the presence or absence obstructive (≥70% luminal diameter stenosis), as well as for plaque composition categorized as non-calcified, calcified or “mixed.” MACE was defined as death, non-fatal myocardial infarction, unstable angina or target vessel revascularization. MACE event rates were compared between patients with or without obstructive plaque and with differing plaque compositions. MACE event rates were significantly higher in patients with obstructive coronary artery stenosis by CCTA compared to those without (61.1% vs. 3.9%, P < 0.01). In patients with obstructive stenosis, mixed (83.3% vs. 25.3%, P < 0.01) and calcified (94.4% vs. 50.7%, P < 0.01) plaque presence was significantly higher than in patients without obstructive stenosis, with no differences in prevalence of non-calcified plaque (27.8% vs. 20.8%, P = NS). For MACE, the negative predictive value of no observed coronary artery plaque was 100% in the follow-up period. In this prospective multicenter study of symptomatic patients with suspected or known CAD undergoing CCTAs interpreted by imagers blinded to patient characteristics, CCTA presence of plaque severity and composition successfully identifies patients at risk for incident MACE events. Importantly, a negative CCTA portends an extremely low risk for incidence MACE.     

Implication of coronary CT angiography combined with four-dimensional speckle tracking echocardiography for predicting major adverse cardiac events

Coronary computed tomography angiography (CCTA) can provide abundant information about the anatomy of the coronary artery. However, this modality is limited in evaluation of myocardial function. Four-dimensional speckle tracking echocardiography (4DSTE) is a novel and sensitive technique for quantitative evaluation of myocardial deformation. We estimated the value of these imaging modalities to predict the risk of MACE in 209 patients with suspected coronary artery disease(CAD) after a median follow-up of 727 days. Three models were established: (1) CCTA alone, (2) CCTA combined with 4DSTE, and (3) CCTA combined with 4DSTE and clinical risk factors. Forty-six (22.0%) patients developed MACE. The hazard ratio (HR) of CCTA classification to predict the risk of MACE was greater (HR?=?4.86) than for other parameters, including B-type natriuretic peptide (BNP) (HR?=?2.44) and left ventricular ejection fraction (LVEF) (HR?=?0.40). The area under the curve of models 2 and 3 to predict MACE was significantly greater than that of model 1 (0.92 and 0.93 vs. 0.84, respectively, p?<?0.001). We conclude that there is direct relationship between CCTA classification and MACE risk. CCTA combined with 4DSTE can improve the ability of CCTA to predict the risk of MACE. This approach provides cardiologists a noninvasive, objective, and efficient method to predict MACE.     

冠状动脉斑块相关参数与血管周围脂肪组织参数的关系

目的 观察冠状动脉斑块相关参数与血管周围脂肪组织(PVAT)参数——冠周脂肪衰减指数(pFAI)及冠周脂肪体素总体积(pFV)的关系。方法 回顾性分析187例因疑诊冠状动脉疾病而接受冠状动脉CT血管造影(CCTA)患者，共218支冠状动脉分支存在斑块。基于CCTA评估斑块相关参数，包括斑块性质(钙化性斑块、混合性斑块及非钙化性斑块)、是否易损斑块、斑块长度和负荷、血管重构状态(无重构、负性重构及正性重构)及血管狭窄程度(轻/中/重度),分析上述参数与pFAI及pFV的相关性。结果 荷混合性及非钙化性斑块血管的PVAT的pFAI高于荷钙化性斑块血管，荷易损斑块血管PVAT的pFAI高于荷非易损斑块血管，pFV与之相反(P均<0.05)。无重构血管PVAT的pFAI低于、pFV高于负性重构及正性重构血管(P均<0.001)。重度狭窄血管PVAT的pFAI高于轻、中度狭窄血管(P均<0.05)。斑块长度及负荷均与pFAI呈线性正相关，与pFV呈线性负相关(P均<0.001)。结论 冠状动脉斑块相关参数均与其pFAI和(或)pFV相关。     

Prognostic value of coronary CT angiography on long-term follow-up of 6.9 years

Long term follow-up of coronary CT angiography (CCTA) is scarce. The aim of the present study was to assess the prognostic value of CCTA over a follow-up period of more than 6 years. 218 Patients were included undergoing 64-slice CCTA. Images were analysed with regard to the presence of nonobstructive (<50 %) or obstructive (50 % stenosis) coronary artery disease (CAD). Major adverse cardiovascular events (MACE) were defined as death, nonfatal myocardial infarction or urgent coronary revascularization. CCTA revealed normal coronaries in 49, nonobstructive lesions in 94, and obstructive CAD in 75 patients. During a median follow-up period of 6.9 years, MACE occurred in 45 patients (21 %). Annual MACE rates were 0.3, 2.7, and 6.0 % (p = 0.001), for patients with normal CCTA, nonobstructive, and obstructive CAD, respectively. Multivariate Cox regression analysis identified the number of segments with plaques [hazard ratio (HR) 1.18, p = 0.002] as well as the presence of obstructive lesions (HR 2.28, p = 0.036) as independent predictors of MACE. The present study extends the predictive value of CCTA over more than 6 years. Patients with normal coronary arteries of CCTA continue to have an excellent cardiac prognosis, while outcome is progressively worse in patients with nonobstructive and obstructive CAD.     

脂蛋白(a)与冠状动脉病变严重程度的关系及对不良心血管事件的影响

目的:探讨脂蛋白(a)[lipopretion(a),Lp(a)]与老年冠状动脉粥样硬化性心脏病(冠心病)患者冠状动脉狭窄程度的相关性及其对主要不良心血管事件(major adverse cardiovascular event,M ACE)的预测价值.方法:回顾性分析复旦大学附属中山医院心内科2014年1月至12月入...     

Association between interleukin-6 and the risk of cardiac events measured by coronary computed tomography angiography

Interleukin-6 (IL-6) has been found to be a predictor of heart attack. We aimed to investigate the relationship of risk factor IL-6 with extent and severity of the coronary artery disease (CAD) evaluated using coronary computed tomography angiography (CCTA). A total of 303 participants without history of CAD undergoing CCTA were enrolled. Using the model of risk-adjusted Cox proportional-hazards, the association of IL-6 level with major adverse cardiac events (MACE) was detected. The participants were assigned into three study groups based on serum IL-6 level. Compared with those in the lowest tertile, patients with highest IL-6 level displayed higher atherosclerotic burden such as plaque extent defined as prevalence of obstructive CAD and segments with any plaque. After a median 3.0 year follow-up period, we also found that patients with highest IL-6 level experienced higher MACE risk and all-cause death compared with those from the lowest tertile. Among participants without CAD history who underwent CCTA, patients with high level of IL-6 had increased burden of atherosclerosis and higher MACE risk compared to participants of low level of IL-6.     

Bridging the gap for lipid lowering therapy: plaque regression,coronary computed tomographic angiography,and imaging-guided personalized medicine

Introduction: Lipid-lowering therapy effectively decreases cardiovascular risk on a population level, but it remains difficult to identify an individual patient’s personal risk reduction while following guideline directed medical therapy, leading to overtreatment in some patients and cardiovascular events in others. Recent improvements in cardiac CT technology provide the ability to directly assess an individual’s atherosclerotic disease burden, which has the potential to personalize risk assessment for lipid-lowering therapy.

Areas covered: We review the current unmet need in identifying patients at elevated residual risk despite guideline directed medical therapy, the evidence behind plaque regression as a potential marker of therapeutic response, and highlight state-of-the-art advances in coronary computed tomographic angiography (CCTA) for measurement of quantitative and qualitative changes in coronary atherosclerosis over time. Literature search was performed using PubMed and Google Scholar for literature relevant to statin therapy and residual risk, coronary plaque regression measurement, and CCTA assessment of quantitative and qualitative change in coronary atherosclerosis.

Expert commentary: We discuss the potential ability of CCTA to guide lipid-lowering therapy as a bridge between population and personalized medicine in the future, as well as the potential barriers to its use.