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心绞痛是心肌缺血最常见的症状之一,其发病人数在全球范围内高达1亿余人[1]。自1904年德国病理学家Marchand提出“动脉粥样硬化”这一定义以来,动脉粥样硬化和心外膜冠状动脉狭窄就一直被视为导致心绞痛的主要原因[2]。然而,近年的研究结果显示,70%的心肌缺血患者通过冠状动脉造影(coronary angiography,CAG)或冠状动脉CT血管造影并未发现明显的冠状动脉狭窄(狭窄程度≥50%)[3]。2020年欧洲非阻塞性冠状动脉缺血疾病专家共识[3]明确定义了缺血伴非阻塞性冠状动脉疾病(ischaemia and non-obstructive coronary arteries,INOCA)。INOCA的病理生理学机制复杂多样,其病因目前尚未完全明确,有研究结果表明,59%~89%的INOCA患者病因是由于冠状动脉微血管功能障碍(coronary microvascular dysfunction,CMD)引起[4- 5]。传统CAG对前小动脉和小动脉等冠状动脉微血管的评估价值有限[6],因此需要寻找一种新型的功能影像检查方法[7-9]。
SPECT心肌灌注显像(myocardial perfusion imaging, MPI)是一种被广泛认可的无创性诊断心肌缺血的功能影像手段,可以通过目测法和半定量参数反映患者心肌缺血的部位和程度。新一代碲锌镉(cadmium zinc telluride, CZT)心脏专用SPECT在性能方面得到了显著提高[10],不仅能获得传统的MPI半定量参数用于评估可逆性心肌缺血,而且还可以实现动态心肌灌注显像(dynamic myocardial perfusion imaging, D-MPI)及心肌血流量(myocardial blood flow, MBF)和心肌血流储备(myocardial flow reserve, MFR)的定量测定,提供全面的诊断信息。动物实验结果已经证实,CZT心脏专用SPECT在冠心病的诊断中具有一定的可行性和准确性[11],与PET测定的MFR的一致性也已得到临床验证[12]。
目前,CZT心脏专用SPECT提供的半定量参数在INOCA与阻塞性冠状动脉粥样硬化性心脏病(obstructive coronary artery disease, OCAD)患者预后评估中的价值已被验证[13]。而基于CZT心脏专用SPECT D-MPI定量参数(以下简称D-MPI定量参数)的预后评估价值方面的文献报道较少[14-15],尤其是关于 D-MPI定量参数与 MPI半定量参数的预后诊断效能的比较研究目前尚未见报道。本研究旨在探讨D-MPI定量参数在INOCA和OCAD患者预后评估中的诊断价值,并与MPI半定量参数进行比较。
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患者中位随访时间为16个月。100例INOCA患者中,无MACE组89例[男性29例、女性60例,年龄54.0(49.0,56.0)岁],有MACE组11例[男性8例、女性3例,年龄52.0(46.0,58.0)岁]。发生MACE的具体情况为心绞痛再住院10例(10.0%)、非致死性卒中1例(1.0%)。有MACE组男性患者比例高于无MACE组(χ2=6.768, P=0.009),但2组患者年龄的差异无统计学意义(Z=−0.011, P=0.991)。
203例OCAD患者中,无MACE组187例[男性112例、女性75例,年龄66.0 (63.0,70.0)岁],有MACE组16例[男性10例、女性6例,年龄67.0 (65.0,70.8)岁]。发生MACE的具体情况为心绞痛再住院11例(5.4%)、非计划性的冠状动脉血运重建2例(1.0%)、心力衰竭1例(0.5%)、非致死性卒中2例(1.0%)。有MACE组和无MACE组患者的性别(χ2=0.042,P=0.838)、年龄(Z=−1.249, P=0.212)的差异均无统计学意义。
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由表1可知,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)。2组的r-MBF及MPI半定量参数[包括SSS、SRS、SDS、负荷TPD(stress TPD, s-TPD)、静息TPD(rest TPD,r-TPD)]的差异均无统计学意义(均P>0.05)。典型病例见图1。
组别 MFR
[M(Q1, Q3)]s-MBF
[ml/(min·g),M(Q1, Q3)]r-MBF
[ml/(min·g),M(Q1, Q3)]MPI半定量参数异常
[例(%)]SSS
[分,M(Q1, Q3)]有MACE组(n=11) 1.65(1.35, 2.04) 1.27(1.03, 1.88) 0.88(0.76, 0.93) 2(18.2) 2.00(1.00, 3.00) 无MACE组(n=89) 2.52(1.75, 3.39) 2.25(1.59, 3.13) 0.91(0.87, 0.93) 13(14.6) 1.00(0.00, 3.00) 检验值 Z=−2.859 Z=−2.986 Z=−1.269 χ2=0.098 Z=−1.013 P值 0.004 0.003 0.204 0.754 0.311 组别 SRS
[分,M(Q1, Q3)]SDS
[分,M(Q1, Q3)]s-TPD
[%,M(Q1, Q3)]r-TPD
[%,M(Q1, Q3)]有MACE组(n=11) 0.00(0.00, 0.00) 1.00(0.00, 3.00) 3.00(1.00, 6.00) 1.00(0.00, 2.00) 无MACE组(n=89) 0.00(0.00, 0.00) 1.00(0.00, 2.00) 1.00(0.50, 3.00) 1.00(0.00, 2.00) 检验值 Z=−0.156 Z=−0.963 Z=−1.543 Z=−0.104 P值 0.876 0.336 0.123 0.917 注: INOCA为缺血伴非阻塞性冠状动脉疾病;MACE为主要不良心血管事件;D-MPI为动态心肌灌注显像;MPI为心肌灌注显像;MFR为心肌血流储备;s-MBF为负荷心肌血流量;r-MBF为静息心肌血流量;SSS为负荷总积分;SRS为静息总积分;SDS为差值总积分;s-TPD为负荷总灌注缺损;r-TPD为静息总灌注缺损;MPI半定量参数异常定义为SSS≥4分且SDS≥2分 表 1 INOCA患者中无MACE组与有MACE组的D-MPI定量参数和MPI半定量参数的比较
Table 1. Comparison of quantitative parameters of dynamic myocardial perfusion imaging (D-MPI) and semi-quantitative parameters of myocardial perfusion imaging (MPI) between non-major adverse cardiovascular events (MACE) group and MACE group in ischaemia and non-obstructive coronary arteries (INOCA) patients
图 1 间断胸骨后疼痛10 d的INOCA患者(男性,58岁)的冠状动脉造影、99Tcm-MIBI心肌灌注显像和心肌血流定量图
Figure 1. Coronary angiography, 99Tcm-sestamibi (MIBI) myocardial perfusion imaging and quantitative myocardial flow images of the ischaemia and non-obstructive coronary arteries (INOCA) patient (male, 58 years old) with intermittent retrosternal pain for 10 days
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由表2可知,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)。而2组间的r-MBF和 MPI半定量参数(包括SSS、SRS、SDS、s-TPD、r-TPD)的差异均无统计学意义(均P>0.05)。
组别 MFR
[M(Q1, Q3)]s-MBF
[ml/(min·g),M(Q1, Q3)]r-MBF
[ml/(min·g),M(Q1, Q3)]MPI半定量参数异常
[例(%)]SSS
[分,M(Q1, Q3)]有MACE组(n=16) 1.51(0.81, 1.91) 1.21(0.61, 1.51) 0.91(0.81, 0.91) 8(50.0) 4.01(2.01, 15.51) 无MACE组(n=187) 2.02(1.50, 2.86) 1.76(1.14, 2.56) 0.89(0.80, 0.93) 75(40.1) 3.00(1.00, 6.00) 检验值 Z=−2.984 Z=−2.891 Z=−1.366 χ2=0.597 Z=−1.777 P值 0.003 0.004 0.172 0.440 0.075 组别 SRS
[分,M(Q1, Q3)]SDS
[分,M(Q1, Q3)]s-TPD
[%,M(Q1, Q3)]r-TPD
[%,M(Q1, Q3)]有MACE组(n=16) 0.01(0.01, 11.01) 2.01(1.31, 5.81) 5.01(2.01, 21.51) 3.51(0.31, 12.81) 无MACE组(n=187) 0.00(0.00, 1.00) 2.00(1.00, 4.00) 3.00(1.00, 8.00) 2.00(1.00, 3.00) 检验值 Z=−1.713 Z=−0.668 Z=−1.297 Z=−1.524 P值 0.087 0.504 0.194 0.127 注: OCAD为阻塞性冠状动脉粥样硬化性心脏病;MACE为主要不良心血管事件;D-MPI为动态心肌灌注显像;MPI为心肌灌注显像;MFR为心肌血流储备;s-MBF为负荷心肌血流量;r-MBF为静息心肌血流量;SSS为负荷总积分;SRS为静息总积分;SDS为差值总积分;s-TPD为负荷总灌注缺损;r-TPD为静息总灌注缺损; MPI半定量参数异常定义为SSS≥4分且SDS≥2分 表 2 OCAD患者中无MACE组与有MACE组的D-MPI定量参数和MPI半定量参数的比较
Table 2. Comparison of quantitative parameters of dynamic myocardial perfusion imaging (D-MPI) and semi-quantitative parameters of myocardial perfusion imaging (MPI) between non-major adverse cardiovascular events (MACE) group and MACE group in obstructive coronary artery disease (OCAD) patients
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由图2可见,ROC曲线分析结果显示,s-MBF和MFR对于预测INOCA患者发生MACE具有较高的诊断效能(AUC=0.777、0.765,均P<0.001)。由表3可知, 当MFR临界值为2.04时,预测INOCA患者发生MACE的灵敏度为81.8%、特异度为66.3%;当s-MBF临界值为1.57 ml/(min·g)时,预测INOCA患者发生MACE的灵敏度为72.7%、特异度为75.3%。r-MBF和MPI半定量参数( 包括SSS、SRS、SDS、s-TPD、r-TPD)的诊断效能相对较弱(AUC=0.617、0.591、0.509、0.586、0.640、0.509,均P>0.05)。Delong检验结果显示,MFR和s-MBF均较SRS有更好的诊断效能,差异均有统计学意义(Z=3.244,P=0.001;Z=3.122,P=0.002)。其余D-MPI定量参数与 MPI半定量参数(包括SSS、SDS、s-TPD、r-TPD)间的差异均无统计学意义(均P>0.05)。采用NRI进一步验证s-MBF及MFR预测INOCA患者发生MACE的诊断效能,以s-MBF≤1.57 ml/(min·g)及MFR≤2.04对INOCA患者预后进行分类,NRI结果显示,与MPI半定量参数异常(SSS≥4分且SDS≥2分)比较,s-MBF≤1.57 ml/(min·g)对INOCA患者预后进行分类时NRI=0.444,正确分类比例提高了44.4%;MFR≤2.04对INOCA患者预后进行分类时NRI=0.445,正确分类比例提高了44.5%。
图 2 CZT心脏专用SPECT D-MPI定量参数和MPI半定量参数预测INOCA患者发生MACE的ROC曲线
Figure 2. Receiver operating characteristic (ROC) curves between quantitative parameters of cadmium zinc telluride (CZT) cardiac SPECT dynamic myocardial perfusion imaging (D-MPI) and semi-quantitative parameters of myocardial perfusion imaging (MPI) for predicting major adverse cardiovascular events (MACE) in ischaemia and non-obstructive coronary arteries (INOCA) patients
参数 AUC(95%CI) 临界值 Youden指数 灵敏度(%) 特异度(%) P值 MFR 0.765(0.670~0.844) 2.04 0.481 81.8 66.3 <0.001 s-MBF[ml/(min·g)] 0.777(0.683~0.854) 1.57 0.480 72.7 75.3 <0.001 r-MBF[ml/(min·g)] 0.617(0.514~0.712) 0.76 0.263 36.4 89.9 0.231 SSS(分) 0.591(0.488~0.688) 0.00 0.211 81.8 39.3 0.276 SRS(分) 0.509(0.407~0.611) 1.00 0.034 0.0 96.6 0.883 SDS(分) 0.586(0.483~0.683) 0.00 0.234 81.8 41.6 0.307 s-TPD(%) 0.640(0.538~0.734) 4.00 0.263 36.4 89.9 0.151 r-TPD(%) 0.509(0.407~0.611) 3.00 0.057 90.9 3.4 0.924 注:CZT为碲锌镉;SPECT为单光子发射计算机体层摄影术;D-MPI为动态心肌灌注显像;MPI为心肌灌注显像;INOCA为缺血伴非阻塞性冠状动脉疾病;MACE为主要不良心血管事件;AUC为曲线下面积;CI为置信区间;MFR为心肌血流储备;s-MBF为负荷心肌血流量;r-MBF为静息心肌血流量;SSS为负荷总积分;SRS为静息总积分;SDS为差值总积分;s-TPD为负荷总灌注缺损;r-TPD为静息总灌注缺损 表 3 CZT心脏专用SPECT D-MPI定量参数和MPI半定量参数预测INOCA患者发生MACE的诊断效能
Table 3. Comparison of quantitative parameters of cadmium zinc telluride (CZT) cardiac SPECT dynamic myocardial perfusion imaging (D-MPI) and semi-quantitative parameters of myocardial perfusion imaging (MPI) for predicting major adverse cardiovascular events (MACE) in ischaemia and non-obstructive coronary arteries (INOCA) patients
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由图3可见,ROC曲线分析结果显示,MFR和s-MBF对于预测INOCA患者发生MACE具有较高的诊断效能(AUC=0.725、0.718,均P<0.001)。由表4可知,当MFR临界值为1.71时,预测OCAD患者发生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患者发生MACE的灵敏度为81.3%、特异度为61.5%。r-MBF和MPI半定量参数(包括SSS、SRS、SDS、s-TPD、r-TPD)的诊断效能相对较弱(AUC=0.603、0.633、0.606、0.550、0.597、0.613,均P>0.05)。Delong检验结果显示,MFR和s-MBF均较SDS有更好的诊断效能,差异均有统计学意义(Z=2.639,P=0.008;Z=2.492,P=0.013)。其余D-MPI定量参数与 MPI半定量参数间的差异均无统计学意义(均P>0.05)。采用NRI进一步验证s-MBF及MFR预测OCAD患者发生MACE的诊断效能,以s-MBF≤1.49 ml/(min·g)及MFR≤1.71对OCAD患者预后进行分类,NRI结果显示,与MPI半定量参数异常(SSS≥4分且SDS≥2分)比较,s-MBF≤1.49 ml/(min·g)对OCAD患者预后进行分类时NRI=0.329,正确分类比例提高了32.9%;MFR≤1.71对OCAD患者预后进行分类时NRI=0.287,正确分类比例提高了28.7%。
图 3 CZT心脏专用SPECT D-MPI定量参数和MPI半定量参数预测OCAD患者发生MACE的ROC曲线
Figure 3. Receiver operating characteristic (ROC) curves between quantitative parameters of cadmium zinc telluride (CZT) cardiac SPECT dynamic dynamic myocardial perfusion imaging (D-MPI) and semi-quantitative parameters of myocardial perfusion imaging (MPI) for predicting major adverse cardiovascular events (MACE) in obstructive coronary artery disease (OCAD) patients
参数 AUC(95%CI) 临界值 Youden指数 灵敏度(%) 特异度(%) P值 MFR 0.725(0.658~0.785) 1.71 0.386 75.0 63.6 <0.001 s-MBF[ml/(min·g)] 0.718(0.651~0.779) 1.49 0.428 81.3 61.5 <0.001 r-MBF [ml/(min·g)] 0.603(0.532~0.670) 0.92 0.226 93.8 28.9 0.115 SSS(分) 0.633(0.563~0.699) 13.00 0.268 37.5 89.3 0.078 SRS(分) 0.606(0.535~0.673) 4.00 0.273 37.5 89.8 0.168 SDS(分) 0.550(0.479~0.620) 1.00 0.124 75.0 37.4 0.488 s-TPD(%) 0.597(0.526~0.665) 11.00 0.261 43.8 82.4 0.257 r-TPD(%) 0.613(0.542~0.680) 4.00 0.361 50.0 86.1 0.212 注:CZT为碲锌镉;SPECT为单光子发射计算机体层摄影术;D-MPI为动态心肌灌注显像;MPI为心肌灌注显像;OCAD为阻塞性冠状动脉粥样硬化性心脏病;MACE为主要不良心血管事件;AUC为曲线下面积;CI为置信区间;MFR为心肌血流储备;s-MBF为负荷心肌血流量;r-MBF为静息心肌血流量;SSS为负荷总积分;SRS为静息总积分;SDS为差值总积分;s-TPD为负荷总灌注缺损;r-TPD为静息总灌注缺损 表 4 CZT心脏专用SPECT D-MPI定量参数和SPECT MPI半定量参数预测OCAD患者发生MACE的诊断效能
Table 4. Comparison of quantitative parameters of cadmium zinc telluride (CZT) cardiac SPECT dynamic myocardial perfusion imaging (D-MPI) and semi-quantitative parameters of myocardial perfusion imaging (MPI) for predicting major adverse cardiovascular events (MACE) in obstructive coronary artery disease (OCAD) patients
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
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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. -
图 1 间断胸骨后疼痛10 d的INOCA患者(男性,58岁)的冠状动脉造影、99Tcm-MIBI心肌灌注显像和心肌血流定量图
Figure 1. Coronary angiography, 99Tcm-sestamibi (MIBI) myocardial perfusion imaging and quantitative myocardial flow images of the ischaemia and non-obstructive coronary arteries (INOCA) patient (male, 58 years old) with intermittent retrosternal pain for 10 days
图 2 CZT心脏专用SPECT D-MPI定量参数和MPI半定量参数预测INOCA患者发生MACE的ROC曲线
Figure 2. Receiver operating characteristic (ROC) curves between quantitative parameters of cadmium zinc telluride (CZT) cardiac SPECT dynamic myocardial perfusion imaging (D-MPI) and semi-quantitative parameters of myocardial perfusion imaging (MPI) for predicting major adverse cardiovascular events (MACE) in ischaemia and non-obstructive coronary arteries (INOCA) patients
图 3 CZT心脏专用SPECT D-MPI定量参数和MPI半定量参数预测OCAD患者发生MACE的ROC曲线
Figure 3. Receiver operating characteristic (ROC) curves between quantitative parameters of cadmium zinc telluride (CZT) cardiac SPECT dynamic dynamic myocardial perfusion imaging (D-MPI) and semi-quantitative parameters of myocardial perfusion imaging (MPI) for predicting major adverse cardiovascular events (MACE) in obstructive coronary artery disease (OCAD) patients
表 1 INOCA患者中无MACE组与有MACE组的D-MPI定量参数和MPI半定量参数的比较
Table 1. Comparison of quantitative parameters of dynamic myocardial perfusion imaging (D-MPI) and semi-quantitative parameters of myocardial perfusion imaging (MPI) between non-major adverse cardiovascular events (MACE) group and MACE group in ischaemia and non-obstructive coronary arteries (INOCA) patients
组别 MFR
[M(Q1, Q3)]s-MBF
[ml/(min·g),M(Q1, Q3)]r-MBF
[ml/(min·g),M(Q1, Q3)]MPI半定量参数异常
[例(%)]SSS
[分,M(Q1, Q3)]有MACE组(n=11) 1.65(1.35, 2.04) 1.27(1.03, 1.88) 0.88(0.76, 0.93) 2(18.2) 2.00(1.00, 3.00) 无MACE组(n=89) 2.52(1.75, 3.39) 2.25(1.59, 3.13) 0.91(0.87, 0.93) 13(14.6) 1.00(0.00, 3.00) 检验值 Z=−2.859 Z=−2.986 Z=−1.269 χ2=0.098 Z=−1.013 P值 0.004 0.003 0.204 0.754 0.311 组别 SRS
[分,M(Q1, Q3)]SDS
[分,M(Q1, Q3)]s-TPD
[%,M(Q1, Q3)]r-TPD
[%,M(Q1, Q3)]有MACE组(n=11) 0.00(0.00, 0.00) 1.00(0.00, 3.00) 3.00(1.00, 6.00) 1.00(0.00, 2.00) 无MACE组(n=89) 0.00(0.00, 0.00) 1.00(0.00, 2.00) 1.00(0.50, 3.00) 1.00(0.00, 2.00) 检验值 Z=−0.156 Z=−0.963 Z=−1.543 Z=−0.104 P值 0.876 0.336 0.123 0.917 注: INOCA为缺血伴非阻塞性冠状动脉疾病;MACE为主要不良心血管事件;D-MPI为动态心肌灌注显像;MPI为心肌灌注显像;MFR为心肌血流储备;s-MBF为负荷心肌血流量;r-MBF为静息心肌血流量;SSS为负荷总积分;SRS为静息总积分;SDS为差值总积分;s-TPD为负荷总灌注缺损;r-TPD为静息总灌注缺损;MPI半定量参数异常定义为SSS≥4分且SDS≥2分 表 2 OCAD患者中无MACE组与有MACE组的D-MPI定量参数和MPI半定量参数的比较
Table 2. Comparison of quantitative parameters of dynamic myocardial perfusion imaging (D-MPI) and semi-quantitative parameters of myocardial perfusion imaging (MPI) between non-major adverse cardiovascular events (MACE) group and MACE group in obstructive coronary artery disease (OCAD) patients
组别 MFR
[M(Q1, Q3)]s-MBF
[ml/(min·g),M(Q1, Q3)]r-MBF
[ml/(min·g),M(Q1, Q3)]MPI半定量参数异常
[例(%)]SSS
[分,M(Q1, Q3)]有MACE组(n=16) 1.51(0.81, 1.91) 1.21(0.61, 1.51) 0.91(0.81, 0.91) 8(50.0) 4.01(2.01, 15.51) 无MACE组(n=187) 2.02(1.50, 2.86) 1.76(1.14, 2.56) 0.89(0.80, 0.93) 75(40.1) 3.00(1.00, 6.00) 检验值 Z=−2.984 Z=−2.891 Z=−1.366 χ2=0.597 Z=−1.777 P值 0.003 0.004 0.172 0.440 0.075 组别 SRS
[分,M(Q1, Q3)]SDS
[分,M(Q1, Q3)]s-TPD
[%,M(Q1, Q3)]r-TPD
[%,M(Q1, Q3)]有MACE组(n=16) 0.01(0.01, 11.01) 2.01(1.31, 5.81) 5.01(2.01, 21.51) 3.51(0.31, 12.81) 无MACE组(n=187) 0.00(0.00, 1.00) 2.00(1.00, 4.00) 3.00(1.00, 8.00) 2.00(1.00, 3.00) 检验值 Z=−1.713 Z=−0.668 Z=−1.297 Z=−1.524 P值 0.087 0.504 0.194 0.127 注: OCAD为阻塞性冠状动脉粥样硬化性心脏病;MACE为主要不良心血管事件;D-MPI为动态心肌灌注显像;MPI为心肌灌注显像;MFR为心肌血流储备;s-MBF为负荷心肌血流量;r-MBF为静息心肌血流量;SSS为负荷总积分;SRS为静息总积分;SDS为差值总积分;s-TPD为负荷总灌注缺损;r-TPD为静息总灌注缺损; MPI半定量参数异常定义为SSS≥4分且SDS≥2分 表 3 CZT心脏专用SPECT D-MPI定量参数和MPI半定量参数预测INOCA患者发生MACE的诊断效能
Table 3. Comparison of quantitative parameters of cadmium zinc telluride (CZT) cardiac SPECT dynamic myocardial perfusion imaging (D-MPI) and semi-quantitative parameters of myocardial perfusion imaging (MPI) for predicting major adverse cardiovascular events (MACE) in ischaemia and non-obstructive coronary arteries (INOCA) patients
参数 AUC(95%CI) 临界值 Youden指数 灵敏度(%) 特异度(%) P值 MFR 0.765(0.670~0.844) 2.04 0.481 81.8 66.3 <0.001 s-MBF[ml/(min·g)] 0.777(0.683~0.854) 1.57 0.480 72.7 75.3 <0.001 r-MBF[ml/(min·g)] 0.617(0.514~0.712) 0.76 0.263 36.4 89.9 0.231 SSS(分) 0.591(0.488~0.688) 0.00 0.211 81.8 39.3 0.276 SRS(分) 0.509(0.407~0.611) 1.00 0.034 0.0 96.6 0.883 SDS(分) 0.586(0.483~0.683) 0.00 0.234 81.8 41.6 0.307 s-TPD(%) 0.640(0.538~0.734) 4.00 0.263 36.4 89.9 0.151 r-TPD(%) 0.509(0.407~0.611) 3.00 0.057 90.9 3.4 0.924 注:CZT为碲锌镉;SPECT为单光子发射计算机体层摄影术;D-MPI为动态心肌灌注显像;MPI为心肌灌注显像;INOCA为缺血伴非阻塞性冠状动脉疾病;MACE为主要不良心血管事件;AUC为曲线下面积;CI为置信区间;MFR为心肌血流储备;s-MBF为负荷心肌血流量;r-MBF为静息心肌血流量;SSS为负荷总积分;SRS为静息总积分;SDS为差值总积分;s-TPD为负荷总灌注缺损;r-TPD为静息总灌注缺损 表 4 CZT心脏专用SPECT D-MPI定量参数和SPECT MPI半定量参数预测OCAD患者发生MACE的诊断效能
Table 4. Comparison of quantitative parameters of cadmium zinc telluride (CZT) cardiac SPECT dynamic myocardial perfusion imaging (D-MPI) and semi-quantitative parameters of myocardial perfusion imaging (MPI) for predicting major adverse cardiovascular events (MACE) in obstructive coronary artery disease (OCAD) patients
参数 AUC(95%CI) 临界值 Youden指数 灵敏度(%) 特异度(%) P值 MFR 0.725(0.658~0.785) 1.71 0.386 75.0 63.6 <0.001 s-MBF[ml/(min·g)] 0.718(0.651~0.779) 1.49 0.428 81.3 61.5 <0.001 r-MBF [ml/(min·g)] 0.603(0.532~0.670) 0.92 0.226 93.8 28.9 0.115 SSS(分) 0.633(0.563~0.699) 13.00 0.268 37.5 89.3 0.078 SRS(分) 0.606(0.535~0.673) 4.00 0.273 37.5 89.8 0.168 SDS(分) 0.550(0.479~0.620) 1.00 0.124 75.0 37.4 0.488 s-TPD(%) 0.597(0.526~0.665) 11.00 0.261 43.8 82.4 0.257 r-TPD(%) 0.613(0.542~0.680) 4.00 0.361 50.0 86.1 0.212 注:CZT为碲锌镉;SPECT为单光子发射计算机体层摄影术;D-MPI为动态心肌灌注显像;MPI为心肌灌注显像;OCAD为阻塞性冠状动脉粥样硬化性心脏病;MACE为主要不良心血管事件;AUC为曲线下面积;CI为置信区间;MFR为心肌血流储备;s-MBF为负荷心肌血流量;r-MBF为静息心肌血流量;SSS为负荷总积分;SRS为静息总积分;SDS为差值总积分;s-TPD为负荷总灌注缺损;r-TPD为静息总灌注缺损 -
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