碲锌镉心脏专用SPECT动态心肌灌注显像定量参数在INOCA和OCAD患者预后评估中的诊断价值

李琳琳; 庞泽堃; 陈越; 汪娇; 李剑明

doi:10.3760/cma.j.cn121381-202307008-00383

碲锌镉心脏专用SPECT动态心肌灌注显像定量参数在INOCA和OCAD患者预后评估中的诊断价值

Diagnostic value of dynamic myocardial perfusion imaging quantitative parameters of cadmium zinc telluride cardiac SPECT in prognostic assessment of patients with INOCA and OCAD

摘要

摘要:
目的探究碲锌镉（CZT）心脏专用SPECT动态心肌灌注显像（D-MPI）定量参数在缺血伴非阻塞性冠状动脉疾病（INOCA）和阻塞性冠状动脉粥样硬化性心脏病（OCAD）患者预后评估中的诊断价值，并与心肌灌注显像（MPI）半定量参数进行比较。
方法回顾性分析2020年3月至2021年7月于泰达国际心血管病医院行CZT心脏专用SPECT D-MPI、具备显像前后3个月内的冠状动脉造影（CAG）资料并最终完成随访的100例INOCA患者其中，男性37例、女性63例，年龄62.0（55.3，66.0）岁和同期诊断为OCAD的203例患者其中，男性122例、女性81例，年龄63.0（57.0，69.0）岁的临床资料，随访内容为主要不良心血管事件（MACE）的发生情况。根据随访结果将INOCA和OCAD患者分别分为无MACE组和有MACE组。比较无MACE组与有MACE组患者的D-MPI定量参数心肌血流储备（MFR）、静息心肌血流量（ r-MBF）和负荷心肌血流量（s-MBF）及MPI半定量参数负荷总积分（SSS）、静息总积分（SRS）、总积分差（SDS）、负荷总灌注缺损（s-TPD）和静息总灌注缺损（r-TPD）间的差异。计量资料的组间比较采用两独立样本t检验或Mann-Whitney U检验，计数资料的组间比较采用Pearson卡方检验。采用受试者工作特征（ROC）曲线评估D-MPI定量参数和MPI半定量参数预测INOCA和OCAD患者发生MACE的诊断效能。采用Delong检验和净重新分类指数（NRI）进一步验证D-MPI定量参数和MPI半定量参数的诊断效能的差异。
结果 100例INOCA患者中，有MACE组的s-MBF和MFR均显著低于无MACE组1.27（1.03，1.88） ml/（min·g）对2.25（1.59，3.13） ml/（min·g）、1.65（1.35，2.04）对2.52（1.75，3.39），差异均有统计学意义（Z=−2.986、−2.859, 均P<0.05）。ROC曲线分析结果显示，s-MBF和MFR对预测INOCA患者发生MACE具有较高的诊断效能曲线下面积（AUC）=0.777、0.765，均P<0.001，当s-MBF临界值为1.57 ml/（min·g）时，预测INOCA患者MACE的灵敏度为72.7%、特异度为75.3%；当MFR临界值为2.04时，预测INOCA患者MACE的灵敏度为81.8%、特异度为66.3%。NRI结果显示，s-MBF≤1.57 ml/（min·g）、MFR≤2.04对于INOCA患者预后的正确分类比例较MPI半定量参数异常（SSS≥4分且SDS≥2分）分别提高了44.4%和44.5%。203例OCAD患者中，有MACE组的s-MBF和MFR均显著低于无MACE组1.21（0.61，1.51） ml/（min·g）对1.76（1.14，2.56） ml/（min·g）、1.51（0.81，1.91）对2.02（1.50，2.86），差异均有统计学意义（Z=−2.891、−2.984，均P<0.05）。ROC曲线分析结果显示，MFR和s-MBF对预测OCAD患者发生MACE具有较高的诊断效能（AUC=0.725、0.718，均P<0.001 ），当MFR临界值为1.71时，预测OCAD患者MACE的灵敏度为75.0%、特异度为63.6%；当s-MBF临界值为1.49 ml/（min·g）时，预测OCAD患者MACE的灵敏度为81.3%、特异度为61.5%。NRI结果显示，s-MBF≤1.49 ml/（min·g）、MFR≤1.71对于OCAD患者预后的正确分类比例较MPI半定量参数异常（SSS≥4分且SDS≥2分）分别提高了32.9%和28.7%。
结论 CZT心脏专用SPECT D-MPI获得的MFR和s-MBF均可以作为预测INOCA及OCAD患者发生MACE的诊断指标，并具有较好的预后诊断效能，与MPI半定量参数相比，能为临床提供更准确的预后评估。

Abstract:
Objective To investigate the diagnostic value of cadmium zinc telluride (CZT) cardiac SPECT dynamic myocardial perfusion imaging (D-MPI) quantitative parameters in prognostic assessment of patients with ischaemia and non-obstructive coronary arteries (INOCA) and obstructive coronary artery disease (OCAD). These parameters were compared with myocardial perfusion imaging (MPI) semi-quantitative parameters.
Methods Retrospective analysis was performed on patients who received CZT cardiac SPECT D-MPI in TEDA International Cardiovascular Hospital from March 2020 to July 2021, had coronary angiography data before and after D-MPI, and completed follow-up. A total of 100 patients with INOCA (37 males and 63 females, aged 62.0(55.3, 66.0) years) and 203 patients with OCAD (122 males and 81 females, aged 63.0(57.0, 69.0) years) were followed for major adverse cardiovascular events (MACE). According to MACE results, patients with INOCA were divided into the MACE and non-MACE groups, similar to patients with OCAD. The D-MPI quantitative parameters (including myocardial flow reserve (MFR), rest myocardial blood flow (r-MBF), and stress myocardial blood flow (s-MBF)) and MPI semi-quantitative parameters (including summed stress score (SSS), summed rest score (SRS), summed different score (SDS), stress total perfusion defect (s-TPD) and rest total perfusion defect (r-TPD)) were compared between the MACE group and the non-MACE group. Two independent sample t-test or the Mann-Whitney U test were used to compare measurement data between groups, and the Pearson′s chi-square test was used to compare counting data between groups. The receiver operating characteristic (ROC) curve was used to evaluate the diagnostic efficacy of quantitative parameters of D-MPI and semi-quantitative parameters of MPI in predicting MACE in patients with INOCA and OCAD. The Delong test and net reclassification index (NRI) were used to verify the differences in diagnostic efficacy between D-MPI quantitative parameters and MPI semi-quantitative parameters.
Results Among the 100 patients with INOCA, s-MBF and MFR in the MACE group were significantly lower than those in the non-MACE group (1.27(1.03, 1.88) ml/(min·g) vs. 2.25(1.59, 3.13) ml/(min·g); 1.65(1.35, 2.04) vs. 2.52(1.75, 3.39)), and the differences were statistically significant (Z=−2.986 and −2.859, both P<0.05). ROC curve analysis showed that s-MBF and MFR had high diagnostic efficiency in predicting MACE in patients with INOCA (area under curve (AUC)=0.777 and 0.765, both P<0.001). When the cut-off value of s-MBF was 1.57 mL/(min·g), the sensitivity and specificity of predicting MACE in patients with INOCA were 72.7% and 75.3%, respectively. When the cut-off value of MFR was 2.04, the sensitivity and specificity of predicting MACE in patients with INOCA were 81.8% and 66.3%, respectively. According to NRI results, the proportion of correct classification in prognosis of INOCA patients with s-MBF≤1.57 ml/(min·g) and MFR≤2.04 was 44.4% and 44.5% higher than that of abnormal MPI semi-quantitative parameters (SSS≥4 and SDS≥2). Among 203 patients with OCAD, s-MBF and MFR in the MACE group were significantly lower than those in the non-MACE group (1.21 (0.61, 1.51) ml/(min·g) vs. 1.76 (1.14, 2.56) ml/(min·g); 1.51 (0.81, 1.91) vs. 2.02(1.50, 2.86)), and the differences were statistically significant (Z=−2.891 and −2.984, both P<0.05). ROC curve analysis showed that MFR and s-MBF had high diagnostic efficacy in predicting MACE in patients with OCAD (AUC=0.725 and 0.718, both P<0.001). When the cut-off value of MFR was 1.71, the sensitivity and specificity of predicting MACE in patients with OCAD were 75.0% and 63.6%, respectively. When the cut-off value of s-MBF was 1.49 ml/(min·g), the sensitivity and specificity of predicting MACE in patients with OCAD were 81.3% and 61.5%, respectively. According to NRI results, the proportion of correct classification in prognosis of OCAD patients with s-MBF≤1.49 ml/(min·g) and MFR≤1.71 was 32.9% and 28.7% higher than that of abnormal MPI semi-quantitative parameters (SSS≥4 and SDS≥2).
Conclusions MFR and s-MBF obtained by CZT cardiac SPECT D-MPI can be used to indicate the occurence of MACE in patients with INOCA and OCAD and have good predictive diagnostic efficacy. Compared with MPI semi-quantitative parameters, MFR and s-MBF provide more accurate prognostic evaluation for clinical practice.

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