冠脈內(nèi)超聲、電子束CT及冠脈造影檢測(cè)冠脈粥樣硬化病變的對(duì)比研究

1、    冠脈內(nèi)超聲、電子束CT及冠脈造影檢測(cè)冠脈粥樣硬化病變的對(duì)比研究         摘要：目的比較和評(píng)價(jià)冠脈內(nèi)超聲(ICUS)、電子束CT(EBCT)及冠脈造影(CAG)檢測(cè)冠脈粥樣硬化病變的價(jià)值。方法10例患者同時(shí)行ICUS、EBCT和CAG檢查。對(duì)所成像的10支靶血管共35個(gè)血管段,逐個(gè)血管段比較分析其檢測(cè)冠脈粥樣病變的結(jié)果。結(jié)果CAG正常的19個(gè)血管段中,9段(47.4%)ICUS顯示粥樣斑塊,斑塊負(fù)荷(33.0±14.0)%(14.5%52.2%),6段

2、(31.6%)EBCT存在鈣化;與ICUS相比,CAG和EBCT診斷冠脈所有病變總的敏感性均為64.0%,特異性分別為100%和90.0%,準(zhǔn)確性分別為74.3%和71.4%(P=0.763);EBCT診斷鈣化斑塊和脂質(zhì)纖維斑塊的敏感性、特異性、陽性預(yù)測(cè)值、陰性預(yù)測(cè)值、準(zhǔn)確性分別為92.3%,77.3%,70.6%,94.4%,82.9%和33.3%,43.5%,23.5%,55.6%,40.0%。結(jié)論對(duì)CAG正常血管,ICUS和EBCT均有助于發(fā)現(xiàn)冠脈早期病變或被CAG低估的病變;以ICUS作為判斷冠脈粥樣病變的“金標(biāo)準(zhǔn)”,EBCT和CAG對(duì)冠脈粥樣斑塊的診斷效率相近;EBCT對(duì)鈣化病變的檢

3、出率較高,對(duì)少部分脂質(zhì)纖維斑塊仍可檢出有鈣鹽沉積。關(guān)鍵詞：超聲檢查,介入性;體層攝影術(shù),X線計(jì)算機(jī);冠狀血管造影術(shù);冠狀動(dòng)脈硬化A comparative study of EBCT,ICUS and CAG for detection of coronary atherosclerosisZHU Jun,SHI Haiming,LUO Xinping,et al.(Department of Cardiology,Huashan Hospital,Shanghai Medical University,Shanghai 200040,China)Abstract：ObjectiveTo an

4、alyze and compare the preliminary results of electron beam computed tomography(EBCT) with those of intracoronary ultrasound (ICUS) and coronary angiography (CAG) for in vivo detection of coronary atherosclerotic plaques.MethodsTen patients (seven males and three females) with an average age of (65&#

5、177;7) years were included in the study.On a site by site basis,35 coronary segments in ten target vessels were analyzed with EBCT,CAG and ICUS.ResultsAtherosclerotic plaque was found by ICUS in nine(47.4%) of 19 segments with normal angiogram,and the plaque burden measured by ICUS was (33.0±14

6、.0)% (14.5%52.2%),coronary calcium deposits were detected by EBCT in 6 (31.6%) segments of angiographically normal segments.Compared with CAG,EBCT yielded a sensitivity of 68.8% and a specificity of 68.4%.Compared with ICUS,an overall sensitivity of EBCT and CAG for detection of the atherosclerosis

7、was both 64.0%,the specificity was 90.0% and 100% and the accuracy was 74.3% and 71.4%,respectively(P=0.763).For plaques with and without ultrasound signs of calcifications,the sensitivity of EBCT was 92.3% and 33.3%,the specificity was 77.3% and 43.5%,the positive predictive value was 70.6% and 23.

8、5%,the negative predictive value was 94.4% and 55.6%,and the accuracy was 82.9% and 40%.ConclusionsEBCT and ICUS imaging may be helpful to identify the atherosclerotic plaques in angiographically normal artery or underestimated lesions.As compared with ICUS,there was no significant difference for th

9、e detection of coronary atherosclerosis between CAG and EBCT.EBCT detects calcified plaques with higher sensitivity and about one-third of soft/fibrous plaques also can be detected.Key words：Ultrasonography,interventional;Tomography,X-ray computed;Coronary angiography;Coronary arteriosclerosis研究表明,冠

10、脈內(nèi)超聲(ICUS)對(duì)冠脈粥樣硬化病變,尤其對(duì)斑塊早期階段的檢測(cè)比冠脈造影(CAG)更具優(yōu)勢(shì),目前已有學(xué)者提出ICUS是診斷冠脈粥樣病變的新的“金標(biāo)準(zhǔn)”1。然而,CAG和ICUS均屬創(chuàng)傷性診斷方法,均有一定的操作并發(fā)癥,患者依從性較差。而無創(chuàng)性電子束CT(EBCT)檢查,由于能夠準(zhǔn)確識(shí)別和定量冠脈鈣化(CAC)而被用來判斷粥樣病變及診斷冠心病。本研究運(yùn)用上述三種診斷方法對(duì)檢測(cè)冠脈粥樣病變作一初步對(duì)比評(píng)價(jià),報(bào)告如下。資料與方法一、研究對(duì)象自1997年12月至1998年4月間,對(duì)我科10例冠脈介入患者進(jìn)行了靶血管的ICUS檢查。男7例,女3例,年齡5475歲,平均(65±7)歲,中位數(shù)年

11、齡64歲。其中穩(wěn)定性心絞痛3例,不穩(wěn)定心絞痛4例,急性心肌梗死1例,胸痛原因待查2例。合并高血壓7例,高膽固醇血癥4例,糖尿病2例,吸煙5例。二、研究方法1.首先以Judkin's法完成CAG,術(shù)后即刻ICUS檢查。使用CIVS INSIGH 血管內(nèi)超聲顯像儀,機(jī)械旋轉(zhuǎn)式超聲導(dǎo)管(探頭頻率 30 MHz,外徑2.9F)。顯像方法參見文獻(xiàn)2。所得像經(jīng)錄像脫機(jī)回放分析。2.在ICUS顯像前后2周內(nèi)行EBCT檢查。采用Imatron公司C-150型掃描成像系統(tǒng),自氣管分叉下相當(dāng)于主肺動(dòng)脈平面起,層厚 3 mm,連續(xù)掃描2030層至心尖部包括整個(gè)心臟。掃描時(shí)要求被檢者屏氣。三、像分析處理1.冠

12、脈血管分段:根據(jù)冠脈解剖標(biāo)志并參照文獻(xiàn)3,4,把冠脈分成左主干及左前降支、左回旋支、右冠脈各近、中、遠(yuǎn)三段共10個(gè)血管段。2.若每血管段上EBCT鈣化積分值1判為EBCT(+);積分為0則EBCT(-)。CAG血管無任何狹窄或斑塊,管腔光滑彈性良好者為CAG(-);管壁僵硬不規(guī)則,管腔狹窄10%或管腔異常擴(kuò)張者判為CAG(+)。如果ICUS顯示冠脈正常三層結(jié)構(gòu)或僅有內(nèi)膜增厚者為正常血管段,ICUS(-);斑塊負(fù)荷10%為斑塊血管段,ICUS(+)。對(duì)斑塊血管段再進(jìn)一步分為脂質(zhì)纖維斑塊和鈣化斑塊(包括混合斑塊)(1)。每血管段均分析最顯著病變處的像。    

13、;3.CAC定量積分按Agatston's法5計(jì)算。四、數(shù)據(jù)分析及統(tǒng)計(jì)學(xué)處理診斷試驗(yàn)的評(píng)價(jià)采用敏感性、特異性、陽性預(yù)測(cè)值(PPV)、陰性預(yù)測(cè)值(NPV)和準(zhǔn)確度;配對(duì)計(jì)數(shù)資料采用McNemar's檢驗(yàn)。P<0.05為有顯著性差異。結(jié)果所有患者均順利進(jìn)行了CAG和ICUS檢查。成像的10支靶血管中,左前降支6例,右冠脈4例。共檢查了36個(gè)血管段,包括左主干6處,左前降支18處,右冠脈12處(其中1處右冠遠(yuǎn)端血管段超聲像不清晰而剔除)。一、與CAG相比,ICUS及EBCT檢測(cè)冠脈粥樣硬化病變的結(jié)果CAG正常的19個(gè)血管段中,10段ICUS亦正常,另9例則存在粥樣斑塊,占47.

14、4%,斑塊負(fù)荷達(dá)(33.0±14.0)%(14.5%52.2%),而EBCT發(fā)現(xiàn)6處鈣化(+),占31.6%;CAG異常的16個(gè)血管段中,ICUS均示有粥樣斑塊的存在(100%),EBCT也發(fā)現(xiàn)11處鈣化(+),占68.8%,另5處積分為0,這5處冠脈狹窄程度(66.0±34.0)%,其中有4處ICUS顯示為脂質(zhì)纖維斑塊。二、與ICUS相比較,EBCT檢測(cè)冠脈粥樣硬化病變的結(jié)果(2)<"t143-1 (7760 bytes)" src="/med/cano/201003/20100323171630607" 74 476>

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17、7078 bytes)" src="/med/cano/201003/20100323171631935" 75 476><"t143-9 (10280 bytes)" src="/med/cano/201003/20100323171631882" 92 476>A、B 分別為左冠脈前降支近段和中段處的ICUS像,顯示冠脈鈣化C、D 為同一患者EBCT的左前降支影像,分別顯示其近段、中段兩處存在鈣化病灶2示 ICUS、EBCT、CAG檢測(cè)冠脈粥樣斑塊病變?cè)?5個(gè)血管段中,ICUS顯示正常血管10段(28.

18、2%),脂質(zhì)纖維斑塊血管12段(34.3%),鈣化斑塊血管13段(37.1%)。在13處鈣化斑塊血管段中,有12處EBCT鈣化(+),占92.3%;22處超聲未顯示鈣化斑塊的血管段中,EBCT仍發(fā)現(xiàn)5處鈣化陽性(22.7%)。12處脂質(zhì)纖維斑塊中,4處EBCT鈣化積分(+),占1/3。10處正常血管段中,ICUS未發(fā)現(xiàn)斑塊,但有1處EBCT鈣化積分為2分。三、檢測(cè)冠脈粥樣硬化病變?cè)\斷方法的評(píng)價(jià)見表1。表1與ICUS比較EBCT和CAG對(duì)冠脈粥樣硬化的檢出結(jié)果(%)檢查方法檢測(cè)對(duì)象敏感度特異性陽性預(yù)測(cè)值陰性預(yù)測(cè)值準(zhǔn)確度EBCT鈣化斑塊92.377.370.694.482.9脂質(zhì)纖維斑塊33.34

19、3.523.555.640.0任何斑塊*64.090.094.150.071.4CAG冠脈斑塊64.0100.0100.052.674.3     注:*McNeman檢驗(yàn),2=0.091,P=0.763討論本研究首次在國(guó)內(nèi)應(yīng)用ICUS、EBCT和CAG對(duì)冠脈粥樣硬化病變的檢測(cè)結(jié)果進(jìn)行了初步比較和評(píng)價(jià)。一、CAG與ICUS對(duì)檢出冠脈粥樣硬化病變的比較本研究CAG與ICUS的對(duì)比研究發(fā)現(xiàn),在CAG正常血管段中,ICUS發(fā)現(xiàn)近一半的血管段存在粥樣斑塊,斑塊負(fù)荷(斑塊面積狹窄百分比)已達(dá)(33.0±14.0)%(14.5%52.2%),表明CAG并不

20、利于發(fā)現(xiàn)早期的粥樣斑塊和實(shí)際病變的嚴(yán)重程度,與國(guó)外報(bào)道結(jié)果相似6-8。其原因可能與動(dòng)脈粥樣硬化早期階段發(fā)生的適應(yīng)性冠脈重構(gòu)有關(guān),即Glagovs現(xiàn)象9。而CAG異常的所有血管段中,ICUS則均能發(fā)現(xiàn)明顯的粥樣斑塊,也進(jìn)一步說明ICUS能更準(zhǔn)確地識(shí)別早期的冠脈病變。因此,對(duì)臨床高度懷疑冠心病但CAG正常的患者,進(jìn)一步ICUS檢查有助于早期或被CAG低估病變的發(fā)現(xiàn),可作為一種與CAG互為補(bǔ)充的新的診斷工具。與ICUS相比,CAG診斷粥樣斑塊的敏感性64.0%,NPV 52.6%,特異性卻達(dá)100%,表明在診斷冠脈粥樣硬化病變上,仍具有一定的價(jià)值。二、EBCT與ICUS檢測(cè)冠脈粥樣硬化病變的比較研究

21、表明,EBCT對(duì)鈣化病變的識(shí)別具有很高的敏感性、特異性10。本組病例中,EBCT診斷鈣化斑塊的敏感性92.3%,NPV 94.4%,準(zhǔn)確性82.9%,與國(guó)外文獻(xiàn)報(bào)道的97.0%,99.0%,82.0%結(jié)果相仿3。但有一處鈣化斑塊,其積分為0,考慮可能系成像中患者屏氣不佳,心臟掃描層面移位漏檢所致。在22段ICUS無鈣化征象的血管中,也發(fā)現(xiàn)5處EBCT鈣化積分達(dá)(5.6±12.2)分,但明顯低于鈣化斑塊的(99.0±94.0)分(P<0.05)。其中33.3%的脂質(zhì)纖維斑塊EBCT存在鈣化,低于國(guó)外報(bào)道的47.0%3。在ICUS正常血管段中,有1處(10.0%)鈣化2分

22、,推測(cè)可能由于ICUS缺乏檢測(cè)動(dòng)脈外膜稀疏呈放射狀分散的鈣鹽,而EBCT則是檢測(cè)整個(gè)部位鈣鹽的沉積量。研究表明,ICUS檢測(cè)鈣化病變主要依賴于鈣化分布的組織學(xué)形式。在粥樣斑塊成熟過程中,斑塊內(nèi)可發(fā)生微鈣化(Microcalcification),由于超聲是根據(jù)鈣化后方聲影診斷的,而聲影的產(chǎn)生需斑塊內(nèi)含有相當(dāng)?shù)拟}鹽量。ICUS在檢測(cè)致密鈣化斑塊時(shí),敏感性可達(dá)90.0%,但對(duì)微鈣化的檢出率僅為64.0%77.0%11,12。因此EBCT對(duì)檢測(cè)鈣鹽在血管上的沉積較ICUS敏感。但從臨床實(shí)用角度來看,由于EBCT不能顯示斑塊性質(zhì),而ICUS卻能準(zhǔn)確了解靶病變的斑塊構(gòu)成和分布,因此,在指導(dǎo)冠脈介入治療時(shí)

23、,ICUS應(yīng)比EBCT更佳。鑒于術(shù)前準(zhǔn)確識(shí)別嚴(yán)重鈣化病變?cè)谥笇?dǎo)冠脈介入性治療中具有非常重要的意義,因此,我們認(rèn)為在有條件的單位,冠脈介入術(shù)前EBCT檢查了解血管鈣化程度,結(jié)合術(shù)中ICUS評(píng)價(jià)斑塊性質(zhì),將有助于降低手術(shù)并發(fā)癥,提高成功率。三、如果均以ICUS作為判斷粥樣病變的“金標(biāo)準(zhǔn)”,EBCT和CAG診斷斑塊的敏感性均為64.0%,特異性分別為90.0%和100%,P=0.763,說明兩種方法診斷粥樣病變的效率一致。只是兩者提供了冠脈粥樣病變不同方面的信息。CAG反映了血管狹窄的嚴(yán)重性;而EBCT則是對(duì)斑塊本身特性的檢測(cè)。本組CAG異常的16段中,有5段積分為0。這5處ICUS發(fā)現(xiàn)4處(80.

24、0%)是脂質(zhì)纖維斑塊,提示EBCT并不能準(zhǔn)確判斷冠脈狹窄的程度。而CAG正常的19例中,有6段(31.6%)鈣化陽性,ICUS均有粥樣斑塊存在,提示冠脈可能發(fā)生重構(gòu)所致。晚近研究13也發(fā)現(xiàn),在CAG正?；蚪跽Ｑ苤?EBCT仍能檢測(cè)出表現(xiàn)為 “點(diǎn)狀”(spotty)鈣化病變,認(rèn)為EBCT能檢測(cè)出表現(xiàn)為早期冠脈重構(gòu)的病變,似乎比CAG更具有優(yōu)勢(shì)。由此看來,通過EBCT鈣化的檢測(cè),可以發(fā)現(xiàn)一些造影正常的血管病變,有利于冠脈輕微病變的檢出。綜上,對(duì)CAG正常血管,ICUS和EBCT均有助于發(fā)現(xiàn)冠脈早期病變或被CAG低估的病變;若以ICUS作為判斷粥樣病變的“金標(biāo)準(zhǔn)”,EBCT和CAG對(duì)冠脈粥樣硬

25、化病變的診斷效率相仿,另外,EBCT對(duì)鈣化病變的檢出率較高,近1/3的脂質(zhì)纖維斑塊也有鈣鹽沉積。作者單位：朱軍(上海醫(yī)科大學(xué)附屬華山醫(yī)院心內(nèi)科200040)施海明(上海醫(yī)科大學(xué)附屬華山醫(yī)院心內(nèi)科200040)羅心平(上海醫(yī)科大學(xué)附屬華山醫(yī)院心內(nèi)科200040)王受益(上海醫(yī)科大學(xué)附屬華山醫(yī)院心內(nèi)科200040)范維琥(上海醫(yī)科大學(xué)附屬華山醫(yī)院心內(nèi)科200040)戴瑞鴻(上海醫(yī)科大學(xué)附屬華山醫(yī)院心內(nèi)科200040)參考文獻(xiàn)：1Waller BF,Pinkerton CA,Slack JD,et al.Intravascular ultrasound:a histologic study of v

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