Value of dobutamine loading/resting SPECT myocardial perfusion imaging in guiding the treatment of coronary heart disease
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摘要:
目的 研究一日法多巴酚丁胺负荷/静息单光子发射计算机断层扫描(SPECT)心肌灌注显像指导治疗冠心病的临床应用价值。 方法 回顾性收集我院2019年5月~2021年7月因胸闷、胸痛就诊的冠心病患者68例,常规行冠状动脉CT血管造影(CCTA),将患者分为两组:研究组(n = 34),同期行一日法多巴酚丁胺负荷/静息SPECT心肌灌注显像并依据SPECT结果选择治疗方案;对照组(n = 34),依据CCTA结果选择治疗方案。确定治疗方案后随诊,比较两组症状缓解率及心血管不良事件发生率,分析SPECT及CCTA推荐的治疗方案差异及原因。 结果 两组间临床病情、冠脉狭窄程度、病变部位及数量差异无统计学意义(P>0.05)。研究组中血运重建治疗3%(1/34),单纯药物治疗97%(33/34),症状缓解率100%;对照组中血运重建治疗50%(17/ 34),单纯药物治疗50%(17/34),症状缓解率100%。研究组血运重建率低于对照组(χ2 = 19.342,P < 0.05)。随诊7~33月(中位数28月),心血管不良事件发生率对照组3%(1/34),研究组为0。研究组有14例患者SPECT的治疗建议与CCTA的治疗建议不同,最终这14例患者均依据SPECT结果选择了单纯药物治疗,比依据CCTA结果做决策的冠脉造影率减少约41%(14/34),单次住院诊疗费用节省约50%。 结论 一日法多巴酚丁胺负荷/静息SPECT心肌灌注显像有利于筛选出不需介入治疗的冠心病患者,其采用单纯药物治疗方案安全有效,相较于目前常用的CCTA筛查,可减少不必要的有创检查及介入手术,降低医疗总费用,缩短住院时间。 -
关键词:
- 负荷/静息SPECT心肌灌注显像 /
- 冠心病 /
- 冠状动脉CT血管造影 /
- 治疗 /
- 多巴酚丁胺
Abstract:Objective To investigate the clinical application value of one-day dobutamine loading/resting single-photon emission computed tomography (SPECT) myocardial perfusion imaging in guiding the treatment of coronary heart disease. Methods A retrospective collection of 68 patients with coronary heart disease who presented to our hospital with chest tightness and chest pain in our hospital from May 2019 to July 2021, routinely underwent coronary computed tomography angiography (CCTA), 34 of them underwent one-day dobutamine loading/resting SPECT myocardial perfusion imaging at the same time, and the therapy was selected based on SPECT results as the study group. The other 34 cases selected the therapy based on CCTA results as the control group. After determining the treatment regimen, the two groups were followed up to compare the rates of symptom relief and cardiovascular adverse events, and to analyse the differences between the treatment regimens recommended by SPECT and CCTA and the reasons for them. Results There were no significant differences in clinical condition and the stenosis degree, lesion location and number of coronary artery between the two groups (P <0.05). In the study group, the patient who was treated with revascularization method accounted for 3% (1/34), the remaining patients treated with drugs alone accounted for 97% (33/34), and the symptom remission rate was 100%. In the control group, those patients which were treated by revascularization method accounted for 50%(17/34), the remaining patients which were treated with drugs alone accounted for 50% (17/34), and the symptom remission rate was 100%. The revascularization rate of the study group was lower than that of the control group (χ2 = 19.342, P <0.05). At 7-33 months follow-up (median 28 months), the incidence of adverse cardiovascular events was 3% in the control group (1/34) and 0 in the study group. 14 patients in the study group had treatment recommendations for SPECT that differed from those for CCTA. In the end, these 14 patients chose drug therapy alone based on SPECT results, which was approximately 41% less than the rate of coronary angiography where decisions were made based on CCTA results (14/34) and a saving of approximately 50% in the cost of a single hospital visit. Conclusion One-day dobutamine loading/resting SPECT myocardial perfusion imaging facilitates the screening of patients with coronary heart disease who do not need interventional therapy. It is safe and effective using a drug-only regimen and reduces the need for unnecessary invasive tests and interventional procedures compared to the currently commonly used CCTA screening, lowering the total cost of care and shortening the length of hospital stay. -
图 1 患者男,58岁,因胸闷、胸痛就诊
A:前降支近中段狭窄50%~60%;B:旋支近段狭窄20%~30%;C:右冠远段闭塞,侧枝循环形成,前降支供血,CCTA建议DSA;D~E:左室心尖部、侧壁心尖部、下侧壁中部-基底部、下壁心尖部-中部-基底部、下间壁中部-基底部心肌灌注稀疏缺损,10%为可逆性缺损,21%为不可逆性缺损,前降支供血区域1%为可逆性缺损,2%为不可逆性缺损,旋支供血区域26%为可逆性缺损,结合CCTA考虑该区域由右冠供血,考虑来源于前降支侧枝循环,12%为不可逆性缺损,右冠供血区域10%为可逆性缺损,68%为不可逆性缺损;F:静息状态下EF值为24%,EDV为149 mL,ESV为113 mL,负荷状态下EF值为29%,EDV为162 mL,ESV为115 mL;SPECT建议单纯药物治疗;G:前降支近中段狭窄80%~90%(黑箭头所示);H:回旋支近段狭窄30%(黑箭头所示);I:右冠远段次全闭塞(白箭头所示);J:右冠复通、复张,支架植入顺利(白箭头所示),血运重建治疗后,患者症状缓解,随诊未发生心血管不良事件.
Figure 1. A 58-year-old male patient presented with chest tightness and chest pain.
图 3 患者男,35岁,1年前曾行回旋支支架植入术,因再发胸闷、胸痛就诊
A:前降支近段狭窄50%~60%;B:回旋支近段高密度支架影,未见明显狭窄及中断;C:右冠近段闭塞,CCTA建议DSA;D~E:左心室下壁心尖部、中部、基底部、下侧壁中部、前侧壁中部心肌灌注稀疏-缺损,其中8%为可逆性缺损,4%为不可逆性缺损,回旋支供血区域22%为可逆性缺损,0%为不可逆性缺损,右冠供血区域9%为可逆性缺损,19%为不可逆性缺损,前降支供血区域心肌灌注未见异常;F:静息状态下EF值为61%,EDV为69 mL,ESV为27 mL,负荷状态下EF值为50%,EDV为91 mL,ESV为46 mL,SPECT建议单纯药物治疗。单纯药物治疗后,患者症状缓解,随诊未发生心血管不良事件.
Figure 3. A 35-year-old male patient who had undergone circumflex stent implantation more than a year ago presented to the hospital due to recurrent chest tightness and chest pain.
表 1 两组患者一般资料及心血管病危险因素比较
Table 1. Comparison of general information and cardiovascular disease risk factors between the two groups (n = 34)
临床资料 研究组 对照组 t/χ2 P 年龄(岁, Mean±SD) 62.24±10.25 64.62±8.02 -1.068 0.289 性别(男/女) 24/10 22/12 0.269 0.604 高血压(有/无) 19/15 22/12 0.553 0.457 高脂血症(有/无) 11/23 8/26 0.657 0.417 糖尿病(有/无) 15/19 9/25 2.318 0.128 吸烟(有/无) 8/26 9/25 0.078 0.779 表 2 两组的冠脉病变严重程度情况比较
Table 2. Comparison of the degree of coronary artery lesions between the two groups (n, n = 34)
项目 研究组 对照组 Z/χ2 P 管腔狭窄程度 -1.216 0.224 0%~49% 9 17 50%~69% 11 4 70%及以上 14 13 冠脉病变情况 左主干/三支血管病变 9/25 10/24 0.073 0.787 单支/多支血管病变 5/29 7/27 0.405 0.525 注:狭窄程度选取左主干、回旋支、前降支以及右冠4支血管中狭窄度最高的血管. -
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