电子束CT检出冠状动脉钙化及其与心肌灌注显像的对比研究

目的比较电子束ＣＴ（ＥＢＣＴ）检查冠状动脉钙化（ＣＡＣ）及核素心肌灌注显像（ＭＰＩ）评价冠心病（ＣＨＤ）的价值。材料与方法本组５０例均为临床疑诊或确诊为ＣＨＤ患者。所有患者均行ＥＢＣＴ、ＭＰＩ及冠状动脉造影。结果４０例患者共８４支血管冠状动脉造影证实有明显的冠状动脉病变（ＣＡＤ）（狭窄＞５０％），其中１４例为单支病变，８例为双支病变，１８例为三支病变，另有１０例冠状动脉造影正常。ＥＢＣＴ预测ＣＡＤ的敏感性、特异性及准确性为８３％、８０％及８２％，ＭＰＩ预测ＣＡＤ的敏感性、特异性及准确性分别为８５％、８０％及８４％，ＥＢＣＴ与ＭＰＩ的结果间无显著性差异（Ｐ＞０．０５）。ＣＡＣ血管供血区出现心肌缺血者达６５％。结论ＣＡＣ是预测ＣＡＤ的有价值指标。在有症状的人群中ＥＢＣＴ检出ＣＡＣ预测ＣＡＤ的敏感性、特异性及准确性与ＭＰＩ相似。有症状人群中检出ＣＡＣ患者多有心肌缺血或梗死，因此为早期诊断冠心病，应对无症状人群进行筛选。     

Accuracy of stress Tc-99m tetrofosmin myocardial perfusion tomography for the diagnosis and localization of coronary artery disease in women

Background  Earlier studies have suggested a modest accuracy of stress thallium 201 myocardial perfusion imaging (MPI) for the diagnosis of coronary artery disease (CAD) in women. The accuracy of stress MPI with technetium 99m tetrofosmin has not been studied in women. The aim of this study was to assess the accuracy of stress Tc-99m tetrofosmin MPI for the diagnosis and localization of CAD in women. Methods and Results  We studied 88 women who underwent exercise or dobutamine stress Tc-99m tetrofosmin tomography and coronary angiography within 3 months. Significant CAD was defined as a stenosis 50% or greater in diameter in at least 1 major epicardial coronary artery. Myocardial perfusion abnormalities were detected in 44 of 53 patients with significant CAD and in 7 of 35 patients without significant CAD (overall sensitivity, 83% [95% confidence interval (CI), 73%-93%]; specificity, 80% [95% CI, 67%-93%]; and accuracy, 82% [95% CI, 74%-90%]). The sensitivity was 72% (18/25) in patients with single-vessel CAD and 93% (26/28) in patients with multivessel CAD. Perfusion abnormalities were detected in 2 or more vascular distributions in 20 of 28 patients with multivessel CAD and in 4 of 60 patients without multivessel CAD (sensitivity for the identification of multivessel CAD, 71% [95% CI, 55%-88%]; specificity, 93% [95% CI, 86%-98%]; and accuracy, 86% [95% CI, 79%-93%]). The sensitivity, specificity, and accuracy were 82%, 84%, and 83%, respectively, for the diagnosis of CAD in the left anterior descending artery; 77%, 84%, and 81%, respectively, for CAD in the right coronary artery; and 74%, 80%, and 78%, respectively, for CAD in the left circumflex artery. Conclusion  Stress Tc-99m tetrofosmin MPI is an accurate noninvasive technique for the diagnosis and localization of CAD in women. Supported in part by a publication grant from GE Healthcare     

Head-to-head comparison of uncorrected and scatter corrected, summed and end diastolic myocardial perfusion SPECT in coronary artery disease

OBJECTIVES: Compared with other non-invasive methods for diagnosing coronary artery disease (CAD), myocardial perfusion imaging (MPI) suffers from some lack of specificity, especially in patients with a small heart. Allowing the assessment of perfusion on end diastolic images instead of summed images, gated single photon emission computed tomography (SPECT) constitutes an attractive method for increasing the accuracy of MPI. Scatter correction, known to improve image contrast, might also be interesting. The present study aimed at comparing scatter corrected to uncorrected gated MPI for CAD diagnosis. METHODS: The results for 100 patients referred for gated 99mTc sestamibi SPECT were analysed. They were divided into two subgroups according to their end systolic volume (ESV) measured by QGS analysis (group A, ESV > or =30 ml, n=65; group B, ESV <30 ml, n=35). For each patient, a total defect score (TDS) was quantified on four polar maps (uncorrected and scatter corrected, summed, and uncorrected and scatter corrected, end diastolic). The optimal TDS separating non-CAD from CAD patients was calculated by analysis of the receiver operating characteristic (ROC) curve for the four data sets, using the coronary angiogram as a 'gold standard'. RESULTS: In the whole patient population, the accuracy of the uncorrected data was 67% for the end diastolic images and 71% for the summed images (sensitivity, 66% and 70%; specificity, 71% and 79%, respectively). After scatter correction, the accuracy did not change for the end diastolic data (accuracy, 67%; sensitivity, 63%; specificity, 93%) and increased to 74% for the summed data (sensitivity, 73%; specificity, 79%). In group A, the uncorrected data were 72% accurate for the end diastolic images and 78% for the summed images (sensitivity, 72% and 79%; specificity, 75% and 75%, respectively). After correction, the accuracy of end diastolic images increased to 77% (sensitivity, 77%; specificity, 75%), and did not change for the summed images (accuracy, 78%; sensitivity, 79%; specificity, 75%). In group B, the accuracy of uncorrected images amounted to 51% for both end diastolic and summed data (sensitivity, 48% and 40%; specificity, 60% and 80%, respectively). After correction, it increased to 57% for the end diastolic images and to 63% for the summed images (sensitivity, 48% and 64%; specificity, 80% and 60%, respectively). CONCLUSIONS: Despite lower blurring on end diastolic compared with summed images, non-scatter corrected end diastolic data were least accurate for the diagnosis of coronary artery disease in patients with a high prevalence of disease. Scatter correction, by improving the delineation of perfusion defects, increased the accuracy of quantitative MPI for the diagnosis of CAD in a large number of patients, more particularly in those with a small heart.     

核素心肌灌注显像与64层螺旋CT诊断冠状动脉疾病的对比研究

目的 对比分析心肌灌注显像（MPI）与64层螺旋CT（MSCT）对冠状动脉疾病（CAD）的诊断价值.方法 对52例可疑和确诊CAD患者（疑诊43例,确诊9例）进行MPI检查,并均在1个月内行冠状动脉造影（CAG）和64层MSCT检查.MPI结果分析采用17节段5分制,获得运动负荷显像灌注总积分和静息显像灌注总积分,两者差值大于1为心肌缺血,判断为阳性.MSCT结果主要以冠状动脉或其主要分支中至少有1支血管管腔狭窄≥50%判定为阳性.以CAG结果为诊断CAD的＂金标准＂.采用SPSS 13.0软件,用Kappa值检验2种方法结果的一致性,两样本率的比较采用配对资料x2检验.结果 MPI和MSCT诊断CAD的灵敏度、特异性、阳性预测值、阴性预测值及准确性分别为86.7%（26/30）、77.3%（17/22）、83.9%（26/31）、81.0%（17/21）、82.7%（43/52）和83.3%（25/30）、86.4%（19/22）、89.3%（25/28）、79.2%（19/24）、84.6%（44/52）;MPI和MSCT对病变血管检出的灵敏度、特异性、阳性预测值、阴性预测值及准确性分别是74.5%（38/51）、81.0%（85/105）、65.5%（38/58）、86.7%（85/98）、78.8%（123/156）和90.2%（46/51）、88.6%（93/105）、79.3%（46/58）、94.9%（93/98）、89.1%（139/156）,2种方法诊断CAD和病变血管差异均无统计学意义（x2=0.44和0.21,P均＞0.05）.MSCT评价病变血管轻度、中度和高度狭窄的灵敏度分别为76.5%（13/17）,78.3%（18/23）和89.6%（43/48）.MPI和MSCT诊断CAD的效能相近,Kappa值为0.64（＜0.75）.25例2种方法均阳性患者,96.0%（24/25）确诊为CAD;18例均阴性的患者,83.3%（15/18）可排除CAD.结论 MPI和MSCT均为筛选、诊断CAD的重要无创检查手段,但信息互补,不可替换.     

Added value of coronary artery calcium score as an adjunct to gated SPECT for the evaluation of coronary artery disease in an intermediate-risk population.

The coronary artery calcium (CAC) score is a readily and widely available tool for the noninvasive diagnosis of atherosclerotic coronary artery disease (CAD). The aim of this study was to investigate the added value of the CAC score as an adjunct to gated SPECT for the assessment of CAD in an intermediate-risk population. METHODS: Seventy-seven prospectively recruited patients with intermediate risk (as determined by the Framingham Heart Study 10-y CAD risk score) and referred for coronary angiography because of suspected CAD underwent stress (99m)Tc-tetrofosmin SPECT myocardial perfusion imaging (MPI) and CT CAC scoring within 2 wk before coronary angiography. The sensitivity and specificity of SPECT alone and of the combination of the 2 methods (SPECT plus CAC score) in demonstrating significant CAD (>/=50% stenosis on coronary angiography) were compared. RESULTS: Forty-two (55%) of the 77 patients had CAD on coronary angiography, and 35 (45%) had abnormal SPECT results. The CAC score was significantly higher in subjects with perfusion abnormalities than in those who had normal SPECT results (889 +/- 836 [mean +/- SD] vs. 286 +/- 335; P < 0.0001). Similarly, with rising CAC scores, a larger percentage of patients had CAD. Receiver-operating-characteristic analysis showed that a CAC score of greater than or equal to 709 was the optimal cutoff for detecting CAD missed by SPECT. SPECT alone had a sensitivity and a specificity for the detection of significant CAD of 76% and 91%, respectively. Combining SPECT with the CAC score (at a cutoff of 709) improved the sensitivity of SPECT (from 76% to 86%) for the detection of CAD, in association with a nonsignificant decrease in specificity (from 91% to 86%). CONCLUSION: The CAC score may offer incremental diagnostic information over SPECT data for identifying patients with significant CAD and negative MPI results.     

Correct spatial normalization of myocardial perfusion SPECT improves detection of multivessel coronary artery disease

BACKGROUND: This study sought to improve the detection of multivessel coronary artery disease (CAD) with the use of rest and exercise single photon emission computed tomography (SPECT) perfusion scintigraphy by developing a processing scheme, which provides proper regional normalization of the images for interpretation. When SPECT perfusion images are interpreted, one area of myocardium serves as "normal." We hypothesized that if this "normal" region changes location from rest to stress, the stress images must be adjusted for proper interpretation. By taking into account the level of tracer activity in this "normal" area on the resting images, we could more accurately identify patients with multivessel CAD.Methods and results Dual-isotope rest (thallium 201) and exercise dobutamine or adenosine stress (technetium 99m sestamibi) perfusion SPECT studies were examined in 258 patients with 2- or 3-vessel CAD on coronary arteriography performed within 6 months of each other (mean interval, 19 days). If a shift in regional location of the "normal" segment from rest to stress was present, the images were (1) interpreted in the usual fashion for the number of vessels with ischemia (PRE-NORM) and (2) reinterpreted after quantitative normalization (ie, adjusting the display window until the intensity of the "normal" segment was matched at rest and stress [POST-NORM]). Interpretation was performed with blinding to arteriographic results. An angiographic stenosis was defined as luminal diameter stenosis greater than 50%. Three control groups comprising (1) single-vessel CAD (n = 119), (2) no significant angiographic CAD (n = 118), and (3) a normalcy group of low pre- and post-test probability of CAD (n = 44) were also studied to determine the incidence of false-positive results induced by the renormalization technique. A shift in the "normal" segment occurred in 81 studies of 258 patients (31%), 80 of which were read as abnormal PRE-NORM (sensitivity, 99%); however, for their 216 stenosed vessels, only 143 were detected PRE-NORM (vessel sensitivity, 66%; accuracy, 65%). The mean POST-NORM change in the display was 11%. POST-NORM, all 82 patients' studies were interpreted as abnormal (sensitivity, 100%), and 196 of 216 vascular territories were abnormal (vessel sensitivity, 91%; accuracy, 83%; both P <.0001 vs PRE-NORM). In the single-vessel disease, no significant disease, and normalcy groups, 19 of 119, 15 of 118, and 11 of 44 patients, respectively, demonstrated a shift in the peak pixel location. However, there were no significant changes in single-vessel sensitivity, angiographic specificity, or normalcy in these patients. CONCLUSIONS: With multivessel CAD, the "normal" region on SPECT often changes in location from rest to stress, potentially masking the extent and severity of multivessel ischemia. Renormalization of the images to match their resting level before image interpretation allows diagnosis of contralateral ischemia and strikingly improves the detection of multivessel CAD, without a substantive loss in specificity.     

99Tcm-替曲膦心肌灌注显像诊断冠心病的临床价值

目的 评价99Tcm-替曲膦MPI对冠心病的诊断价值.方法 对73例临床怀疑冠心病的患者[男46例,女27例,年龄(61.16±12.95)岁],行99Tcm-TF MPI,第1天行静息显像,次日行运动或药物负荷显像.1周内行CAG,以其结果为“金标准”,计算99Tcm-TF MPI诊断冠心病的灵敏度、特异性和准确性等.结果 在73例患者中,43例CAG阳性,其中MPI阳性32例,阴性11例.单支病变27例,双支病变10例,三支病变6例.共65支病变血管,累及LAD 33支,LCX 16支,RCA 16支.30例CAG阴性,其中MPI阴性25例,阳性5例.99Tcm-TF MPI对冠心病诊断的灵敏度74.4％(32/43),特异性83.3％(25/30),阳性预测值86.5％(32/37),阴性预测值69.4％(25/36),准确性为78.1％(57/73).诊断单支、双支及三支病变患者的灵敏度分别为66.7％(18/27)、80.0％(8/10)和5/6.99Tcm-TF MPI诊断病变血管的灵敏度为67.7％(44/65),特异性为89.0％ (137/154).结论 99Tcm-TF MPI对冠心病有较好的诊断价值,是继99Tcm-MIBI之后又一优良的心肌灌注显像剂.     

Impact of myocardial perfusion imaging with PET and (82)Rb on downstream invasive procedure utilization, costs, and outcomes in coronary disease management.

We hypothesized that PET myocardial perfusion imaging with (82)Rb (PET MPI), would reduce downstream utilization of diagnostic arteriography, compared with SPECT, in patients matched for pretest likelihood of coronary disease (pCAD). PET MPI is more accurate for assessment of impaired coronary flow reserve compared with SPECT MPI, potentially reducing the demand for subsequent arteriography, percutaneous trans-coronary intervention, and coronary artery bypass grafting (CABG), with attendant cost savings, while avoiding a negative impact on coronary events. METHODS: The frequency of diagnostic arteriography, revascularization, costs, and 1-y clinical outcomes in 2,159 patients studied with PET MPI was compared with 2 control groups studied with SPECT MPI matched to the PET group by pCAD: an internal control group of 102 patients and an external SPECT control group of 5,826 patients. CAD management costs were approximated with realistic global fee estimates. RESULTS: Arteriography rates were 0.34 and 0.31 for the external and internal control SPECT groups and 0.13 for the patients studied with PET (P < 0.0001). pCAD averaged 0.39 in patients studied with PET MPI, and in the external SPECT control group, and 0.37 in the internal SPECT controls. Revascularization rates were 0.13 and 0.11 for external and internal SPECT patients and 0.06 for the PET group (P < 0.0001; P < 0.01), with a cost savings of 30% noted for PET patients, with no significant difference in cardiac death or myocardial infarction at 1-y follow-up. CONCLUSION: PET MPI in patients with intermediate pCAD results in a >50% reduction in invasive coronary arteriography and CABG, a 30% cost savings, and excellent clinical outcomes at 1 y compared with SPECT.     

High-efficiency SPECT MPI: Comparison of automated quantification, visual interpretation, and coronary angiography

Background

Recently introduced high-efficiency (HE) SPECT cameras with solid-state CZT detectors have been shown to decrease imaging time and reduce radiation exposure to patients. An automated, computer-derived quantification of HE MPI has been shown to correlate well with coronary angiography on one HE SPECT camera system (D-SPECT), but has not been compared to visual interpretation on any of the HE SPECT platforms.

Methods

Patients undergoing a clinically indicated Tc-99m sestamibi HE SPECT (GE Discovery 530c with supine and prone imaging) study over a 1-year period followed by a coronary angiogram within 2 months were included. Only patients with a history of CABG surgery were excluded. Both MPI studies and coronary angiograms were reinterpreted by blinded readers. One hundred and twenty two very low (risk of CAD < 5%) or low (risk of CAD < 10%) likelihood subjects with normal myocardial perfusion were used to create normal reference limits. Computer-derived quantification of the total perfusion deficit at stress and rest was obtained with QPS software. The visual and automated MPI quantification were compared to coronary angiography (≥70% luminal stenosis) by receiver operating curve (ROC) analysis.

Results

Of the 3,111 patients who underwent HE SPECT over a 1-year period, 160 patients qualified for the correlation study (66% male, 52% with a history of CAD). The ROC area under the curve (AUC) was similar for both the automated and the visual interpretations using both supine only and combined supine and prone images (0.69-0.74). Using thresholds determined from sensitivity and specificity curves, the automated reads showed higher specificity (59%-67% vs 27%-60%) and lower sensitivity (71%-72% vs 79%-93%) than the visual reads. By including prone images sensitivity decreased slightly but specificity increased for both. By excluding patients with known CAD and cardiomyopathies, AUC and specificity increased for both techniques (0.72-0.82). The use of a difference score to evaluate ischemic burden resulted in lower sensitivities but higher specificities for both automated and visual quantification. There was good agreement between the visual interpretation and automated quantification in the entire cohort of 160 unselected consecutive patients (r = 0.70-0.81, P < .0001).

Conclusions

Automated and visual quantification of high-efficiency SPECT MPI with the GE Discovery camera provides similar overall diagnostic accuracy when compared to coronary angiography. There was good correlation between the two methods of assessment. Combined supine and prone stress imaging provided the best diagnostic accuracy.     

负荷-静息心肌灌注显像对老年人冠心病的诊断价值

目的探讨负荷-静息心肌灌注显像对老年人冠心病的诊断价值。方法205例疑诊冠心病的老年患者[≥60（67±5）岁],行^99Tc^m-甲氧基异丁基异腈（MIBI）负荷-静息心肌灌注显像（运动负荷185例,药物负荷20例）和冠状动脉造影检查,排除曾行经皮冠状动脉介入治疗（PCI）及冠状动脉旁路移植术（CABG）者。以冠状动脉造影为“金标准”,评价负荷-静息心肌灌注显像诊断老年冠心病的灵敏度、特异性和准确性。采用SPSS 15．0软件对数据行χ^2检验。结果以冠状动脉管腔狭窄〉50％作为诊断标准,205例患者中冠状动脉造影阳性57例（28％）,其中单支病变30例,双支病变19例,三支病变8例。冠状动脉造影结果阳性的患者中核素负荷-静息心肌灌注显像异常者36例;冠状动脉造影阴性148例（72％）患者中,负荷-静息心肌灌注显像正常者135例。对照冠状动脉造影结果,负荷-静息心肌灌注显像对老年人冠心病总的诊断灵敏度63％（36／57）,特异性91％（135／148）,准确性83％（171／205）;对单支、双支以及三支病变的诊断灵敏度分别为57％（17／30）、58％（11／19）和8／8。行运动负荷显像患者185例,按照运动试验是否达到目标心率分为2组：组1运动试验高峰心率达到目标心率,共53例（29％）;组2运动试验高峰心率未达到目标心率,共132例（71％）。2组心肌灌注显像诊断冠心病的灵敏度分别为81％（13／16）和58％（22／38）。组1诊断灵敏度高于组2,但经χ^2检验,两者之间差异无统计学意义（χ^2=2．69,P=0．1）。结论负荷-静息心肌灌注显像是诊断老年人冠心病的可靠方法;当运动负荷达到目标心率时,核素心肌灌注显像诊断冠心病的灵敏度较高。     

Cardiac CT angiography (CTA) and nuclear myocardial perfusion imaging (MPI)-a comparison in detecting significant coronary artery disease

RATIONALE AND OBJECTIVES: Endowed with sufficient diagnostic accuracy, electron beam computed tomography angiography (CTA) is being increasingly used to evaluate coronary arteries. However, data on direct comparisons with nuclear myocardial perfusion studies are limited. In this study, we sought to compare the accuracies of CTA and myocardial perfusion imaging (MPI) for identifying symptomatic patients with hemodynamically significant obstructive coronary artery disease (CAD). MATERIALS AND METHODS: In a single-center study, symptomatic outpatients who were scheduled for cardiac catheterization were prospectively enrolled. Only patients with exertional angina or dyspnea were included. After fulfilling the inclusion criteria, 30 patients were enrolled in the study (mean age 54 +/- 9 years and 70% males). Patients underwent MPI, CTA including coronary artery calcification (CAC) measure, and invasive coronary angiography for evaluation of obstructive coronary artery disease. Significant CAD was defined as >50% left main artery stenosis or >70% stenosis of any other epicardial vessel by invasive angiography. The sensitivities, specificities and predictive values of MPI, CAC, and CTA were analyzed per patient RESULTS: CTA demonstrated significant higher sensitivity than MPI (95% vs. 81%, P < .05). CTA demonstrated significantly higher specificity than both MPI (89% versus 78%, P = .04) and CAC (56%, P = .002). CTA also performed better in a per-vessel analysis (sensitivity 94%, specificity 96%) than both nuclear and CAC. There were no significant differences between the sensitivities and specificities of MPI and CAC. CONCLUSION: CTA accurately detects obstructive CAD in symptomatic patients and may be more accurate than MPI or CAC assessment. Larger studies in a more diverse population are needed.     

A new algorithm for the quantitation of myocardial perfusion SPECT. II: validation and diagnostic yield.

This study validates a new quantitative perfusion SPECT algorithm for the assessment of myocardial perfusion. The algorithm is not based on slices and provides fully 3-dimensional sampling and analysis independent of assumptions about the geometric shape of the left ventricle. METHODS: Radiopharmaceutical- and sex-specific normal limits and thresholds for perfusion abnormality in 20 segments of the left ventricle were developed for separate, dual-isotope rest 201Tl-exercise 99mTc-sestamibi SPECT in 36 patients with <5% before-scanning likelihood of coronary artery disease (CAD) (group 1) and 159 patients with perfusion abnormalities (group 2). These thresholds were validated in 131 patients (group 3) by comparison with expert visual interpretation. Thresholds for automatic segmental scores were developed and validated for groups 2 and 3, respectively. The accuracy of CAD detection was assessed in 94 patients, who underwent coronary angiography (group 4). RESULTS: Overall sensitivity for detection of stress and rest segmental perfusion abnormality was 91% and 96%, respectively, for men and 89% and 79%, respectively, for women. Overall specificity for stress and rest was 87% and 90%, respectively, for men and 88% and 90%, respectively, for women. Agreement between automatic and visual scores was good (weighted K of 0.71 and 0.60 for stress and rest images, respectively). Sensitivity and specificity were 88% for the detection of > or =70% stenosis. For the detection of left anterior descending, left circumflex, and right coronary artery stenosis, sensitivity was 84%, 86%, and 88%, respectively, and specificity was 84%, 88%, and 81%, respectively. CONCLUSION: The new quantitative perfusion SPECT approach is highly sensitive and specific for the detection and localization of CAD, provides accurate automatic scores for the assessment of regional perfusion, and overcomes the low-specificity limitations of previous quantitative algorithms.     

Accuracy of non-invasive techniques for diagnosis of coronary artery disease and prediction of cardiac events in patients with left bundle branch block: a meta-analysis

Purpose Non-invasive evaluation of coronary artery disease (CAD) in patients with left bundle branch block (LBBB) has limitations inherent to different tests, and the relative merits of these tests are unclear. This meta-analysis assessed the accuracy of the frequently used non-invasive techniques, including exercise electrocardiography (ECG), myocardial perfusion imaging (MPI) and stress echocardiography (SE), for detection of CAD and prediction of cardiac events in patients with LBBB. Methods A review was conducted of all reports on detection of CAD and prediction of cardiac events in patients with LBBB (published between January 1970 and December 2004), and revealed 55 diagnostic and nine prognostic reports with sufficient details to calculate test accuracy. Weighted (by sample size) sensitivity and specificity were calculated. Summary relative risk ratios (95% confidence intervals) were calculated. Results Overall sensitivity was higher for exercise ECG and (quantitatively analysed) MPI than for SE (83.4% and 88.5% versus 74.6% respectively, p<0.0001). SE had a higher specificity (88.7%) than MPI (41.2%) and exercise ECG (60.1%) (p<0.0001). Based on analysis of eight reports, the relative risk of cardiac death or myocardial infarction in patients with an abnormal SE and MPI was elevated more than sevenfold, but it did not differ by imaging modality (p=0.9). Conclusion Meta-analysis of non-invasive CAD assessment in LBBB patients revealed that exercise ECG and MPI had the highest sensitivity, while SE had the highest specificity. The prognostic accuracy of MPI and SE appeared similar.     

SPECT／CT显像评价“功能相关冠状动脉病变”的价值

目的探讨SPECT／CT显像评价“功能相关冠状动脉（简称冠脉）病变”的可行性及临床价值。方法40例可疑或确诊冠心病患者同机完成^99Tcm-甲氧基异丁基异腈（MIBI）负荷／静息心肌灌注断层显像和冠脉CT造影（CTCA）。负荷／静息心肌灌注显像采用标准二日法,首日行腺苷负荷心肌灌注显像,次日行静息心肌灌注显像及CTCA。腺苷按患者体质量以0．84mg·kg^-1·min^-1经静脉泵匀速给药,CTCA使用标准自动对比剂跟踪扫描程序完成。通过专用融合软件将心肌血流灌注与冠脉三维成像图融合,评价心肌缺血与冠脉病变的相关关系,确定“功能相关冠脉病变”。结果40例患者,CTCA正常20例,异常20例;120支冠脉中共检出33支病变血管,累及左前降支15支,左回旋支9支,右冠脉9支。心肌灌注显像正常22例,心肌缺血和（或）心肌梗死18例。SPECT心肌灌注和CTCA融合图像显示供血区心肌血流灌注正常且无狭窄冠脉占总的无狭窄冠脉的92．47％（86／93）,狭窄〈75％的冠脉中,其供血区心肌缺血或梗死的阳性率占42．86％（6／14,例）,狭窄〉75％或闭塞冠脉中,其供血区心肌缺血的阳性率占92．31％（12／13,例）。120支冠状动脉中20．83％（25／120,支）的病变冠脉为“功能相关冠脉病变”,检测出27例患者中25．93％（7／27,例）有无狭窄病变的冠脉导致心肌缺血;使15．38％（2／13,例）冠脉病变患者免除有创性诊断检查;指导对42．86％（6／14,例）的狭窄〈75％冠脉行药物治疗或冠脉血管重建术治疗;为1支狭窄〉75％的冠脉无需行血管重建术提供依据。结论SPECT／CT心肌灌注和CTCA融合显像可确定“功能相关冠脉病变”,可提供综合信息诊断冠心病和指导治疗。     

99m Tc-MIBI心肌显像对冠状动脉病变的定位研究

目的：探讨９９ｍＴｃ－ＭＩＢＩ心肌显像在检出冠心病病变心肌节段和病变血管定位上的价值。方法：对照分析２０例冠心病和５例对照组冠状动脉造影与９９ｍＴｃ－ＭＩＢＩ单光子发射断层显像（ＳＰＥＣＴ）的结果。结果：潘生丁负荷ＳＰＥＣＴ检出冠心病、病变血管和病变心肌节段的敏感性分别为９５．００％、６３．６４％和４３．６８％明显高于静息相的６０．００％、４２．４２％和２７．５９％（Ｐ＜０．０１）。与静息相比较,潘生丁负荷ＳＰＥＣＴ多发现３３．３３％的病变血管和３６．８４％的病变心肌节段。对病变血管的敏感性,ＬＡＤ高于ＲＣＡ和ＬＣＸ;对于病变心肌节段检测敏感性ＲＣＡ支配节段高于ＬＡＤ和ＬＣＸ,特异性均较高。结论：潘生丁ＳＰＥＣＴ能显著提高冠心病的检出,有效估计病变心肌范围和病变冠状动脉     

^99Tc^m—MIBI心肌灌注显像评价代谢综合征患者心肌血流

目的应用MPI评价代谢综合征（MS）患者心肌血流灌注情况。方法选择确诊或疑似冠心病患者342例行常规门控运动＋静息MPI;根据代谢指标异常情况分为4组,组1：无代谢指标异常;组2：具有1个代谢指标异常;组3：具有2个代谢指标异常;组4：具有3个或3个以上代谢指标异常。分析代谢指标异常数量与MPI的关系。对符合中华医学会糖尿病分会MS诊断标准、在显像前后1个月内行CAG检查的103例患者的MPI结果,以CAG结果为标准,分析2种方法间诊断的一致性。采用SPSS13．0软件,组间心肌灌注异常的发生率比较采用x。检验,方法间的一致性分析用Kappa检验。结果（1）与CAG比较,MPI诊断冠心病的灵敏度为80．5％（33／41）,特异性85．5％（53／62）,阳性预测值78．6％（33／42）,阴性预测值86．9％（53／61）,诊断准确性为83．5％（86／103）,惭值为0．657,P〈0．001。（2）随代谢指标异常数量增加,心肌灌注异常的发生率增加：组1为23．3％（10／43）,组2为32．9％（26／79）,组3为54．4％（56／103）,组4为57．3％（67／117）,X2：23．22,P〈0．001。结论MPI可以应用于IS患者的心肌血流评估;代谢指标异常数量增加,心肌灌注异常的发生率增加。     

新型心肌灌注显像剂^99Tc^m-N-DBODC5诊断冠心病的临床价值

目的 探讨[二（二甲氧丙基膦基乙基）-乙氧乙胺]-[二（氧-乙氧乙基）二硫代氨基]锝氮配合物（^99Tc^m-N-DBODC5）对可疑冠心病患者的临床诊断价值.方法 将2010年10月至2012年10月间46例可疑冠心病患者[男31例,女15例,平均年龄60岁]按就诊先后顺序编号,同一患者随机分配进行^99Tc^m-N-DBODC5和^99Tc^m-MIBI运动-静息MPI检测冠心病及病变血管,2种显像剂的MPI在1周内完成,并在4周内行CAG.以CAG结果为“金标准”,^99Tc^m-N-DBODC5和^99Tc^m-MIBIMPI结果分别与其进行一致性检验,不同显像剂诊断效能的比较行χ^2检验.结果 46例可疑冠心病患者中,CAG阳性29例,阴性17例.^99Tc^m-N-DBODC5和^99Tc^m-MIBI MPI诊断冠心病的灵敏度均为86％ （25/29）,特异性分别为88％（15/17）和65％（11/17）,两者诊断冠心病效能差异无统计学意义（χ^2=2.62,P＞0.05）;138支冠状动脉血管中,CAG阳性48支,阴性90支.^99Tc^m-N-NDBODC5与^99Tc^m-MIBI MPI诊断病变血管效能差异也无统计学意义（χ^2=3.79,P＞0.05）.诊断冠心病方面,^99Tc^m-N-DBODC5 MPI与CAG结果的一致性较好（Kappa=0.73）,^99Tc^m-MIBI MPI与CAG结果的一致性中等（Kappa=0.52）.结论 ^99Tc^m-N-DBODC5对冠心病患者具有一定诊断价值,可作为心肌灌注显像剂应用于临床.     

腺苷负荷心肌灌注显像评价心肌血流供应异常的临床研究

目的 回顾性分析腺苷负荷/静息心肌灌注显像用于评价冠心病心肌血流供应异常的准确性和临床价值.方法 1858例临床确诊或可疑冠心病患者行常规标准程序两日法腺苷负荷/静息99Tcm-甲氧基异丁基异腈心肌灌注断层显像,由2位以上核医学科医师共同阅片定性分析图像.所有患者在显像前后1个月内行冠状动脉（简称冠脉）造影检查.方法间的一致性分析用Kappa检验,Kappa＞0.45为一致性较好.结果 1858例患者中,冠脉造影有1支及1支以上冠脉狭窄≥50%的患者957例,其中单支病变506例,双支病变256例,三支病变195例;共累及冠脉1603支,其中左前降支（LAD）765支、左回旋支（LCX）399支、右冠脉（RCA）439支.腺苷负荷/静息心肌灌注显像示心肌缺血或心肌梗死者1126例,与冠脉造影对照,其诊断冠心病的灵敏度为91.54%（876/957）,特异性为72.25%（651/901）,阳性预测值为77.80%（876/1126）,阴性预测值为88.93%（651/732）,2种方法一致性好（Kappa=0.641）.对LAD、LCX和RCA病变诊断的灵敏度分别为81.31%（622/765）,56.64%（226/399）和70.62%（310/439）;对单支、双支和三支冠脉病变的灵敏度分别为87.55%（443/506）,94.92%（243/256）和97.44%（190/195）.腺苷不良反应的发生率为84.12%（1563/1858）,无严重心脏事件发生.结论 腺苷负荷心肌灌注断层显像诊断冠心病有较高的灵敏度、特异性和准确性,对评价心肌血流供应异常有重要的临床价值.     

Comparison of spiral multidetector CT angiography and myocardial perfusion imaging in the noninvasive detection of functionally relevant coronary artery lesions: first clinical experiences.

Compared with conventional coronary angiography, spiral multidetector CT (MDCT) angiography has delivered promising accuracy in the detection and validation of coronary lesions. Myocardial perfusion imaging (MPI) using SPECT is an established method for noninvasively assessing the functional significance of coronary stenoses and delivers valuable information for risk stratification. This retrospective analysis compared the accuracies of MDCT angiography and MPI in the detection of hemodynamically relevant lesions of the coronary arteries. METHODS: Twenty-five patients with suspected or known coronary artery disease were studied. Electrocardiographically gated MPI and 16-MDCT angiography were performed. Myocardial perfusion images were analyzed by 2 experienced observers, and reversible and fixed perfusion defects were detected and allocated to their corresponding coronary vessels. For the evaluation of MDCT angiography, image quality was determined, and lesions > or = 50% and luminal narrowing < 50% were visually assessed and characterized by 2 independent observers unaware of the results of MPI. RESULTS: Ninety-nine coronary vessels were analyzed, and the quality of MDCT angiography images was assessed for 330 coronary segments. Coronary artery diameter was interpretable for 231 (70%) of 330 segments, whereas in 99 (30%) of 330 segments, vessel diameter could not be evaluated because of heavy calcifications, blurring, motion artifacts, or intracoronary stents. MDCT angiography detected stenoses > or = 50% in 15 of 100 coronary arteries. Eight (53%) of 15 stenoses > or = 50% showed reversible or fixed perfusion defects in the corresponding myocardial areas on MPI. Sensitivity, specificity, and negative and positive predictive values were 100%, 87%, 100%, and 29%, respectively, for the ability of MDCT angiography to detect reversible perfusion defects in the corresponding myocardial areas. CONCLUSION: MDCT angiography detected myocardial ischemia, as defined by reversible perfusion defects on MPI, with a positive predictive value of 29% in a nonselected study cohort. Compared with MPI alone, MDCT angiography added important morphologic information, but MPI remains mandatory for evaluating the functional relevance of coronary artery lesions.     

Diagnostic pathway of integrated SPECT/CT for coronary artery disease

Treatment strategy in patients with suspected coronary artery disease (CAD) is driven by symptomatology in combination with diagnostic evaluation of the extent and/or severity of atherosclerosis in the coronary arteries and ischemia in the myocardium, i.e., the anatomic and functional correlates of CAD. Whereas multislice row computed tomography (MSCT) has the advantage of detecting coronary atherosclerosis at its earliest stages, thereby allowing initiation of appropriate therapeutic measures well before development of obstructive CAD, myocardial perfusion imaging (MPI) SPECT can clarify the hemodynamic consequences of the anatomic findings on MSCT based on a functional assessment of myocardial blood flow. There is a lack of correlation between coronary artery calcium (CAC), coronary artery stenosis, and MPI SPECT. Therefore CAC scoring and stress MPI should be thus considered complementary approaches rather than exclusionary in the evaluation of the patient at risk for CAD. The integration of anatomic and functional information may provide additional information for the clinician by the improved risk stratification and diagnostic accuracy of integrated techniques. The majority of previous studies are based on a sequential flowchart, starting with either SPECT or CAC scoring that finally directs the therapeutic strategy. Patients at low risk for CAD can be selected for primary prevention, and patients at high risk for CAD can be directly selected for coronary angiography (CAG). The remaining group of patients at intermediate risk for CAD can be substratified into lower- and higher-risk categories based on the presence or absence of stress-induced ischemia on MPI SPECT and CAC scoring. An integration of SPECT and CAC as a starting point for CAD detection in symptomatic patients at intermediate risk for CAD may facilitate a tailored diagnostic as well as therapeutic approach. Finally, using SPECT/CT, MPI SPECT, and CAC findings may be completed with CT angiography. The development of SPECT/CT hybrid systems is therefore of important value for the nuclear cardiology armamentarium. This editorial commentary outlines a diagnostic pathway of integrated SPECT/CT for CAD assessment in symptomatic patients at intermediate risk for CAD.