核心脏病学的临床应用价值.ppt

1、0,核心脏病学,评价是否有心肌缺血，部位，量化程度和范围评价心肌梗死部位是否有存活心肌，存活心肌的量，范围和程度评价左心室整体功能：EDV,ESV, LVEF评价局部功能：局部室壁运动，室壁增厚率评价左心室收缩同步性,心肌灌注,存活心肌 梗死心肌,收缩同步性,左心室整体功能,1,I,I,A,C,I,C,B,I,I,A,2014 ESC 血运重建指南,2015 ESC NSTE-ACS 指南,核心脏病学在冠心病诊断中的应用,2,Eur J Nucl Med (2002) 29:16081616,Sensitivity and specificity by patient for the dete

2、ction of any coronary stenosis greater than 50% in 137 patients undergoing perfusion imaging for diagnostic purposes,核心脏病学在冠心病诊断中的应用,Myocardial perfusion imaging with SPECT,3,Canadian Journal of Cardiology 29 (2013) 285e296,核心脏病学在冠心病诊断中的应用,Clinical pre-test probabilitiesa in patients with stable che

3、st pain symptoms,建议：对于冠脉造影正常且有症状的患者（特别是糖尿病患者），可行核心脏病学相关检查，明确是否存在心肌缺血或心肌血流储备下降的情况,Stable chest pain patients,4,核心脏病学在冠心病诊断中的应用,Stable chest pain patients,The CE-MARC 2 trial,John P. Greenwood, et al. JAMA, 2016.,PTL：pre-test likelihood,核心脏病学在冠心病诊断中的应用,Acute chest pain patients,J Am Coll Cardiol. 2016

4、 Feb 23;67(7):853-79.,CCTA Ccath Exercise ECGCMR (Stress/Rest ) SPECT/PET (Stress/Rest )Echocardiography (Stress/Rest),Cardiovascular Imaging,核心脏病学在冠心病诊断中的应用,J Am Coll Cardiol. 2016 Feb 23;67(7):853-79.,Early Assessment Pathway: imaging may be used early in the evaluation process, with the goal of r

5、uling in or ruling out ACS or MI through the identification of wall motion abnormalities, perfusion defects, or obstructive CAD without the need to wait for serial biomarker analysis.,核心脏病学在冠心病诊断中的应用,J Am Coll Cardiol. 2016 Feb 23;67(7):853-79.,Observational pathway : The second pathway is referred

6、to as the observational pathway, and it involves serial analysis of cardiac bio- markers to rule in or out myocardial necrosis and MI.,8,Nat Rev Cardiol.2016 13(5):266-75,核心脏病学在冠心病诊断中的应用,I,A,I,C,9,核心脏病学指导冠心病治疗,2,10,核心脏病学指导SCAD治疗,对于SCAD患者，血运重建带来的获益很可能被手术相关风险所抵消，SCAD患者是否行血运重建仍有争议,11,COURAGE trial: 入选2

7、287例SCAD患者, 随机分为PCI组（N=1149）和药物治疗组（N=1138），随访2.57年（平均4.6年）,N Engl J Med 2007;356:150316.,核心脏病学指导SCAD治疗,对于SCAD患者, PCI较药物保守治疗未见获益,12,Indications for revascularization in patients with stable angina or silent ischemia,aWith documented ischaemia or FFR 0.80 for diameter stenosis ,90%. bClass of recommen

8、dation.cLevel of evidence.CAD=coronary artery disease; FFR=fractional flow reserve; LAD=left anterior descending coronary artery; LV =left ventricular.,SPECT Trials-Ischemic burdern97. Impact of ischaemia and scar on the therapeutic benefit derived from myocardial revascularization vs. medical thera

9、py among patients undergoing stress-rest myocardial perfusion scintigraphy. Eur Heart J 2011;32(8):1012 1024. 99. Optimal medical therapy with or without percutan- eous coronary intervention to reduce ischemic burden: results from the Clinical Outcomes Utilizing Revascularization and Aggressive Drug

10、 Evaluation (COURAGE) trial nuclear substudy. Circulation 2008;117(10):1283 1291. 143. Comparison of the short-term survival benefit associated with revascularization compared with medical therapy in patients with no prior coronary artery disease undergoing stress myocardial perfusion single photon

11、emission computed tomography. Circulation 2003;107(23):2900 2907. .,2014 ESC 血运重建指南,核心脏病学指导SCAD治疗,核心脏病学识别存活心肌,Int J Cardiol.2015 186():111-6,VIAMI trial：216例梗死区存在未行直接PCI的STEMI患者， 4878h后行“冬眠心肌”检查，随机分为侵入治疗组（n=106）和保守治疗组（n=110）,存在冬眠心肌的患者早期侵入治疗较保守治疗获益更大,核心脏病学识别存活心肌,Eur J Nucl Med Mol Imaging (2005) 32:4

12、30437,253例既往MI并存在“冬眠心肌”的患者，分为血运重建组（n142）和药物治疗组（n111）,15,This allows for accurate triage of patients by MPI for consideration of revascularization. Patients without ischemia can be safely managed with optimal medical therapy.,核心脏病学指导CTO治疗,HCE=hard cardiac events,J Nucl Cardiol 2013;20:5638.,16,核心脏病学指

13、导冠心病治疗,Matched,Unmatched（存活心肌）,17,冠状动脉微循环（尸检）,冠状动脉造影,核心脏病学在冠心病诊断中的应用,18,Matched,Unmatched,核心脏病学评价冠心病预后,19,核心脏病学评价冠心病预后,2010 ESC 血运重建指南,Indications of different imaging tests for the diagnosis of obstructive CAD and for the assessment of prognosis in subjects without known CAD,aFor the prognostic ass

14、essment of known coronary stenosis, functional imaging is similarly indicated.,20,N=2,783Events=137,核心脏病学评价冠心病预后,Circulation. 2011;124:2215-2224.,Univariate predictors of cardiac death,采集时间长注射剂量相对高灵敏度相对低不能更早期发现疾病不能同时对多种核素显像肥胖患者伪影严重无法绝对测定血流量和血流储备,传统的A-SPECT指导血运重建有一定的局限性,CZT改变了心脏核医学的历史,CZT半导体新一代探测器,D-

15、SPECT,更新换代产品,D-SPECT 人工智能+机器人技术 开创心脏核医学新历程,以心脏为中心，追心扫描,Scan time: 49 secFWHM: 5mm,Scan time: 600 secCollimator: LEGPFWHM: 11mm,A-SPECT,1 mm,D-SPECT,Co 57 线源,-10,0,10,190mm,新一代D-SPECT为指导冠心病诊治提供新的可能,检查时间: 10 倍扫描速度图像质量: 2 倍分辨率,Nuclear Medicine No Clear Medicine?,D-SPECT 2 Mins,传统A-SPECT 25Mins,D-SPECT

16、不仅仅是快，而且已经达到PET/CT的分辨率,D-SPECT更精确、更精准,传统SPECT的辐射剂量为： 9-15 mSv最新D-SPECT辐射剂量为： 1-3mSv ，检查一次低于全年自然本底辐射水平！,D-SPECT辐射剂量低、更安全,mSv 辐射剂量,D-SPECT 动态扫描可以定量分析测得CFR,Coronary Flow Reserve （CFR）, Measures integrated hemodynamic effects of epicardial CAD, diffuse atherosclerosis, vessel remodeling and microvascula

17、r dysfunction on myocardial tissue perfusion,Courtesy of Drs. Taqueti and Di Carli, Brigham and Womens Hospital,FFR与CFR大约40%的情况下存在不匹配,JACC.2012;5:193-202,冠脉造影管腔狭窄程度不能准确反映冠脉血流储备CFR,J AmColl Cardiol Img 2009;2:100923,Coronary Flow Reserve Associates With Risk Independent of Traditional Ischemia Measur

18、es,N= 2,783CD= 137,Source: Murthy VL, et al. Circulation. 2011;124(20):2215-24, Coronary flow reserve, even in the absence of flow-limiting CAD, identifies patients at risk for cardiac death,CFR,Ischemia,CFR Differentiates Risk of Cardiac Death in Diabetics,P=0.07,P=0.33,P=0.005,P=0.65,P=0.015,*Adju

19、sted for Duke score, ischemia + scar, rest LVEF and early revascularization,N=2423CD=122,Source: Murthy VL, et al. Circulation. 2012;126:1858-1868,Coronary Flow Reserve, Revascularization, and Outcomes,Source: Taqueti VR, et al. Circulation 2015 Jan 6;131(1):19-27, Only patients with angiographic ob

20、struction AND low CFR seem to benefit for revasc, especially CABG,CFR in Prognosis and Therapy,OMT +/- Revasc,OMT,What is OMT?,Which Revasc Strategy?,Prognosis:,GOOD,POOR,Therapy:,Take Home Messages,核心脏病学对冠心病患者通过评估心肌缺血和心肌存活，对冠心病患者明确诊断，危险分层，指导治疗方案的制定和估测预后均有重要价值新一代D-SPECT的应用为指导冠心病血运用重建提供了新的可能核心脏病学检查对指导个体化的冠心病治疗方案的制定有重要价值,