Cardiac failure in coronary heart disease

Cardiac failure, which used to be rare in coronary heart disease, is now its most common complication. Coronary heart disease can cause or appear as cardiac failure through one or more of 12 mechanisms: acute myocardial infarction, acute reversible ischemia, right ventricular dysfunction, cardiogenic shock, acute mitral regurgitation, ventricular septal perforation, cardiac free wall rupture, ischemic cardiomyopathy, ventricular aneurysm, coexisting diseases, iatrogenesis, and pseudoheart failure. An understanding of the responsible mechanism or mechanisms is essential not only for appropriate treatment but also for prognostication. Various therapeutic modalities, both medical and surgical, should be able to improve not only symptoms but also survival. Current efforts in the management of patients with cardiac failure as a result of coronary heart disease should be aimed at prevention, both primary and secondary.     

双源CT冠脉成像与冠脉造影诊断冠心病的对比研究

目的：评价双源CT（DSCT）冠状动脉成像与冠状动脉造影（CAG）在冠心病诊断中的价值。方法：对38例临床疑诊冠心病患者169支冠状动脉同时进行了DSCT冠状动脉成像和CAG检查,以CAG诊断冠心病为标准分析DSCT冠状动脉成像诊断冠心病的各项指标的表现。结果：DSCT冠状动脉成像判断冠脉中、重度狭窄（狭窄≥50％）的敏感度、特异度、准确度、阳性预测值、阴性预测值分别为93．75％（45／48）,99．17％（120／121）,97．63％（165／169）,97．83％（45／46）,97．56％（120／123）。DSCT冠状动脉成像与CAG对各支冠状动脉狭窄程度的显示具有较好的一致性（Kappa=0．921,P〈0．001）。两种检查方法在发现冠状动脉疾病方面无显著差异（P〉0．05）。结论：双源CT冠状动脉成像显示冠脉病变具有较高的敏感性和特异性,已成为冠心病诊断的一种可靠、无创的有效方法。     

128层螺旋CT冠状动脉成像在冠心病诊断中的应用价值

目的评价128层螺旋CT(128-SCT)冠状动脉成像在冠心病诊断中的应用价值。方法入选临床诊断为冠心病并行128-SCT冠脉成像检查的患者60例,在128-SCT检查后的4周内行冠状动脉造影(CAG)检查。以CAG检查结果为金标准,以冠状动脉节段为单位,对比分析各节段128-SCT及CAG检查结果,评估128-SCT诊断冠状动脉狭窄程度的准确性,同时计算128-SCT诊断冠心病的敏感性、特异性、阳性预测值、阴性预测值、诊断指数、诊断符合率及Kappa值等统计学指标。结果共评估60例患者的715个冠状动脉节段,对比CAG的结果,128-SCT有664个节段检查结果与CAG相符合,符合率达92.87%。128-SCT诊断冠心病的灵敏度为79.05%,特异度为98.52%,阳性预测值为90.22%,阴性预测值为96.47%,诊断符合率为95.66%,Kappa值为0.818。结论 128-SCT冠状动脉成像检出冠心病准确性较好,可作为诊断与排除冠心病的无创性检查方法。     

冠状动脉双源CT与冠状动脉造影成像对急诊胸痛患者诊断冠心病的价值

目的:以常规冠状动脉造影(CAG)为"金标准",探讨急诊胸痛患者双源CT(DSCT)冠状动脉血管成像诊断冠心病的价值,分析DSCT诊断冠心病的准确度、灵敏度、特异度、阳性预测值和阴性预测值。方法:对115例以胸痛为主诉的急诊就诊、临床怀疑冠心病拟行CAG的患者[男60例,女55例,平均年龄(66.37±10.29)岁]进行DSCT冠状动脉成像,统计分析DSCT对诊断冠状动脉不同程度狭窄冠心病的准确度、灵敏度及特异度,并与CAG结果对比。结果:共获得92例有诊断价值的病例,DSCT诊断冠状动脉中重度狭窄的准确度为94.6%,灵敏度、特异度、阳性预测值和阴性预测值分别为96.7%、90.6%、95.1%和93.5%。对于诊断轻度狭窄冠心病的灵敏度为70.6%,特异度为63.9%,阳性预测值为34.3%,阴性预测值为91.2%。结论:DSCT冠状动脉成像可作为临床冠心病可疑患者CAG手术前的预筛手段,当患者的冠状动脉为中重度狭窄时,诊断的准确度、灵敏度、特异度较高,DSCT与CAG有很好的一致性,其对是否需进一步CAG检查有较大的指导意义。DSCT对于冠状动脉轻度狭窄患者的阴性预测值较高,提示如果DSCT判定患者无冠状动脉病变,基本上无进一步行CAG的必要。     

Understanding the heart: CT and MRI for coronary heart disease

Methods of noninvasive evaluation of coronary artery disease-including multidetector row computed tomography, electron beam computed tomography, magnetic resonance imaging, and nuclear studies (single photon emission computed tomography, positron emission tomography)-are reviewed.     

Cardiac magnetic resonance imaging in patients with coronary disease

Opinion statement Cardiac magnetic resonance (CMR) has emerged as a versatile noninvasive tool for the comprehensive evaluation of patients with suspected or established coronary artery disease (CAD). In a single imaging session, CMR can assess left ventricular anatomy and function, myocardial perfusion, viability, and coronary luminal stenosis. Using specific pulse sequences, left ventricular global and regional function can be assessed by cine CMR at rest and in response to inotropic stress; first-pass perfusion quantified by vasodilator stress; myocardial viability evaluated by delayed enhancement imaging and also by functional reserve; and coronary artery stenosis assessed by angiography. All these modalities can be achieved with high spatial resolution and image contrast, without exposure to ionizing radiation, and within a reasonable time frame of about 1 hour of scan time. Also, the imaging planes can be programmed to provide identical views of the heart for each type of image, thereby facilitating intermodality comparisons. There is early but accumulating evidence that the accuracy and prognostic values of many of these modalities are comparable or superior to radionuclide scintigraphy and echocardiography in head-to-head studies. Current limitations unique to CMR include the inability to perform exercise stress testing inside the CMR suite and exclusion of patients with indwelling metallic devices such as defibrillators and pacemakers. Despite these limitations, CMR is unique in its multifaceted approach that can be specifically tailored to the clinical question at hand, making it arguably the best tool for the diagnosis and management of CAD. With the rapid pace of advancement in CMR hardware and pulse sequence technologies, the clinical use of this powerful technique is likely to grow even greater in this area.     

Magnetic resonance imaging in the assessment of coronary artery disease

Magnetic resonance imaging (MRI) is gaining importance in cardiology as the noninvasive test of choice for patients with a multitude of cardiovascular problems. Recently, cardiovascular MRI has emerged as an important noninvasive diagnostic modality in the assessment of coronary artery disease. Because of its superior spatial resolution, integration of qualitative and quantitative methodology, and excellent reproducibility, MRI has advantages over conventional noninvasive modalities currently used in the evaluation of coronary artery disease. This article reviews the rapidly expanding recent literature that has now established cardiovascular MRI as an ideal choice in the evaluation of myocardial ischemia (including dobutamine cine MRI and vasodilator perfusion MRI techniques). We further discuss the role of delayed contrast-enhanced MRI and low-dose dobutamine cine MRI for evaluation of myocardial viability. Comparisons with more established techniques, such as dobutamine stress echocardiography, single-photon emission computed tomography perfusion imaging, and positron emission tomography, are reviewed.     

腺苷对心血管系统的作用及在评价冠心病中的应用

腺苷是一种较强的血管扩张剂 ,对心血管系统有多重作用。其与导管技术、核素心肌灌注显像、冠状动脉内超声或经胸超声等技术结合可用于冠状动脉血流储备研究、冠心病的诊断及评价存活心肌等。     

冠状动脉256排CT与冠状动脉造影对冠心病的诊断比较

目的冠状动脉256排CT成像技术与冠状动脉造影检查对冠状动脉粥样硬化性心脏病的诊断比较。方法选取2013年5月至2014年5月内蒙古兴安盟人民医院心血管内科疑似冠心病患者50例,其中男性29例,女性21例,年龄37~68岁。先行冠状动脉256排CT扫描及图像后处理,后行冠状动脉造影检查,将两结果进行对比分析。结果以冠状动脉狭窄≥50%者为阳性。冠状动脉256排CT诊断冠心病灵敏度为40.00%,特异度98.18%,阳性预测值88.89%,阴性预测值81.82%,正确指数38.18%,符合率82.67%,KAPPA值46.28%。结论冠状动脉造影诊断冠心病准确性优于冠状动脉CT。冠状动脉CT可对冠心病患者进行初筛诊断。     

Magnetic resonance imaging in the assessment of valvular heart disease

Although Doppler echocardiography remains the most frequently used imaging modality for assessing valvular heart disease, the technique has a number of limitations that could affect the quality of imaging studies and make the results difficult to interpret. Cardiac magnetic resonance (CMR) imaging could be superior to echocardiography in a number of ways: for example, for assessing ventricular dimensions, volumes, function and mass, for quantifying valvular regurgitation, and for investigating areas of myocardial fibrosis and extracardiac structures. In carrying out these tasks, CMR uses a variety of pulse sequences that are specially created to obtain information on specific tissue characteristics or on particular aspects of blood flow through heart valves. This general review article focuses on the usefulness of CMR in the clinical diagnosis of valvular heart disease and reviews how the data acquired using the technique can be incorporated into algorithms for the clinical management of patients with significant valvular heart lesions.     

Cardiac catheterization and other imaging modalities in the evaluation of valvular heart disease

This review describes recent publications using cardiac catheterization and diagnostic imaging modalities, excluding transesophageal and transthoracic echocardiography, to evaluate valvular heart disease. Radionuclide techniques and magnetic resonance imaging continue to be studied as to whether they can improve the quantification of valvular regurgitation. As yet, however, they are not justified in the routine evaluation of patients with valvular heart disease. Cardiac catheterization has been used by several authors to assess more completely the obstructive physiology of valve stenosis, including obtaining a better understanding of transvalvular pressure gradients; the phenomenon of downstream pressure recovery; and the utility of valve resistance in quantifying the severity of the valve stenosis, which complements the calculated valve area, especially in cases of low cardiac output. Traditional cardiac catheterization techniques have recently been used to show a sex difference in left ventricular systolic performance in aortic stenosis. Intracardiac ultrasound and electrocardiography are being studied as methods to guide percutaneous valvotomy. The analysis of myocardial tissue samples obtained by endocardial biopsy promises understanding gene-protein-function interactions. Specifically, myosin alterations in aortic valve disease and protooncogene expression in hypertrophy are exciting, emerging areas of investigation.     

Cardiac rehabilitation and exercise training in secondary coronary heart disease prevention

Substantial evidence indicates that increased levels of physical activity, exercise training, and overall cardiorespiratory fitness provide protection in primary and secondary coronary heart disease (CHD) prevention. Clearly, cardiac rehabilitation and exercise training (CRET) programs have been greatly underused in patients with CHD. We review the benefits of formal CRET programs on CHD risk factors including exercise capacity, obesity indices, plasma lipids, inflammation, and psychosocial stress as well as overall morbidity and mortality. These data support the fact that patients with CHD, especially after major CHD events, need routine referral to CRET programs; and patients should be vigorously encouraged to attend these valuable programs.     

螺旋CT冠状动脉校正性对比剂浓度联合心肌灌注显像在冠心病诊断价值

目的:探讨螺旋CT冠状动脉校正性对比剂浓度,联合心肌灌注显像对冠心病预后的判断价值。方法:选取2017年3月至2018年2月,在我院接受数字减影血管造影(DSA)检查的冠心病患者211例作为研究对象,按照冠状动脉左前降支狭窄程度≥70%为严重狭窄组(n=121)和冠状动脉左前降支狭窄程度<50%的轻度狭窄组(n=90)。所有患者均进行CCO差值、心肌灌注显像相位参数(静息BW和SD、负荷BW和SD)检测,观察分析对应数据。通过Logistic回归分析与冠心病密切关联的指标,与CCO差值进行联合检测。采用ROC曲线分析具有差异的指标来预测冠心病预后的效能。结果:严重狭窄组患者的CCO差值、BW_(静息)、SD_(静息)、BW_(负荷)、SD_(负荷)均高于轻度狭窄组,差异有统计学意义(P<0.05)。多因素Logistics回归分析显示CCO差值、BW_(静息)、BW_(负荷)是冠状动脉左前降支狭窄率≥70%的危险因素。单独进行CCO差值的检测诊断冠状动脉左前降支狭窄率的灵敏度80.17%,特异度78.89%;CCO差值联合心肌灌注显像BW_(静息)及BW_(负荷)检测的灵敏度为92.56%,高于单独检测值,特异度为65.56%,低于单独检测值。分析CCO差值、BW_(静息)、BW_(负荷)在预测冠心病预后的AUC面积为:CCO差值(0.675)、BW_(静息)(0.868)、BW_(负荷)(0.850),并以最大约登指数计算出CCO差值、BW_(静息)、BW_(负荷)最大AUC面积相应参数截止值,其中CCO差值截止值为0.190(敏感度=72.30%,特异性=69.80%);BW_(静息)截止值为0.534(敏感度=82.20%,特异性=88.90%);BW_(负荷)截止值为0.473(敏感度=83.40%,特异性=86.20%)。结论:螺旋CT冠状动脉校正性对比剂浓度联合心肌灌注显像检测能够提高灵敏度,降低特异度,从而显著提高对冠心病诊断的准确率,对预后防治具有重要意义。     

Advances in imaging for assessment of ischemic heart disease

Cardiac imaging techniques continue to develop for the noninvasive detection and evaluation of patients with coronary artery disease. These techniques include single photon and positron emission tomography along with computed tomography and magnetic resonance imaging. The new myocardial perfusion tracers 99mTc-hexakis-2-methoxyisobutyl-isonitrile and 99mTc-teboroxime have recently come into general use for these purposes, and their role alongside that of more traditional agents is currently being defined using new imaging protocols and instrumentation. 99mTc-hexakis-2-methoxyisobutyl-isonitrile has also been documented as an important research tool for evaluating both at-risk myocardium and the degree of subsequent myocardial salvage following reperfusion therapies for acute myocardial infarction. Antimyosin antibody imaging is another emerging approach in the evaluation of patients with acute myocardial infarction. Metabolic imaging with 18F-fluoro-2-deoxyglucose using positron emission tomography to detect myocardial segments with compromised blood flow but preserved glucose metabolism is currently the best noninvasive method of identifying viable myocardium in patients with left ventricular dysfunction who may benefit from revascularization. Insights from these studies have led to development of the current 201Tl stress-rest reinjection protocols for viability evaluation using single photon emission computed tomography. Positron emission tomography, in combination with blood flow tracers using kinetic modeling, provides accurate estimates of coronary blood flow and flow reserve. The use of these new imaging techniques will allow increasingly accurate evaluation of patients with suspected and proven coronary artery disease in the future.     

多层螺旋CT冠心病诊断进展

随着现代医学影像学技术的发展,多层螺旋CT（MSCT）冠状动脉成像技术目前作为临床诊断冠心病（CHD）首选的无创性检查方法,近年已成为影像学研究的热点。本文通过MSCT对冠状动脉钙化、狭窄、斑块性质、术后改变、心脏功能5个方面评价的综合分析,综合阐述了MSCT在诊断CHD中发挥的重要作用。