核心臟病學(xué)的臨床應(yīng)用價(jià)值

1、0,核心臟病學(xué),,評價(jià)是否有心肌缺血，部位，量化程度和范圍評價(jià)心肌梗死部位是否有存活心肌，存活心肌的量，范圍和程度評價(jià)左心室整體功能：EDV,ESV, LVEF評價(jià)局部功能：局部室壁運(yùn)動(dòng)，室壁增厚率評價(jià)左心室收縮同步性,,,心肌灌注,存活心肌 梗死心肌,收縮同步性,左心室整體功能,1,I,I,A,C,I,C,B,I,,I,A,,,,,2014 ESC 血運(yùn)重建指南,2015 ESC NSTE-ACS 指南,核心臟病學(xué)在冠心病診斷

2、中的應(yīng)用,2,Eur J Nucl Med (2002) 29:1608–1616,Sensitivity and specificity by patient for the detection of any coronary stenosis greater than 50% in 137 patients undergoing perfusion imaging for diagnostic purposes,核心臟病學(xué)在冠心病診

3、斷中的應(yīng)用,,Myocardial perfusion imaging with SPECT,3,Canadian Journal of Cardiology 29 (2013) 285e296,核心臟病學(xué)在冠心病診斷中的應(yīng)用,,Clinical pre-test probabilitiesa in patients with stable chest pain symptoms,,建議：對于冠脈造影正常且有癥狀的患者（特別是糖尿病患

4、者），可行核心臟病學(xué)相關(guān)檢查，明確是否存在心肌缺血或心肌血流儲(chǔ)備下降的情況,Stable chest pain patients,4,核心臟病學(xué)在冠心病診斷中的應(yīng)用,,Stable chest pain patients,The CE-MARC 2 trial,John P. Greenwood, et al. JAMA, 2016.,PTL：pre-test likelihood,核心臟病學(xué)在冠心病診斷中的應(yīng)用,,Acute ches

5、t pain patients,,,,,,J Am Coll Cardiol. 2016 Feb 23;67(7):853-79.,CCTA Ccath Exercise ECGCMR (Stress/Rest ) SPECT/PET (Stress/Rest )Echocardiography (Stress/Rest),Cardiovascular Imaging,核心臟病學(xué)在冠心病診斷中的應(yīng)用,,,,,,J Am Co

6、ll Cardiol. 2016 Feb 23;67(7):853-79.,Early Assessment Pathway: imaging may be used early in the evaluation process, with the goal of ruling in or ruling out ACS or MI through the identification of wall motion abnormalit

7、ies, perfusion defects, or obstructive CAD without the need to wait for serial biomarker analysis.,核心臟病學(xué)在冠心病診斷中的應(yīng)用,,,,,,J Am Coll Cardiol. 2016 Feb 23;67(7):853-79.,Observational pathway : The second pathway is referred

8、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,核心臟病學(xué)在冠心病診斷中的應(yīng)用,,I,A,I,C,9,,,,,核心臟病學(xué)指導(dǎo)冠心病治療,,2,10

9、,,核心臟病學(xué)指導(dǎo)SCAD治療,對于SCAD患者，血運(yùn)重建帶來的獲益很可能被手術(shù)相關(guān)風(fēng)險(xiǎn)所抵消，SCAD患者是否行血運(yùn)重建仍有爭議,,11,COURAGE trial: 入選2287例SCAD患者, 隨機(jī)分為PCI組（N=1149）和藥物治療組（N=1138），隨訪2.5～7年（平均4.6年）,,N Engl J Med 2007;356:1503­16.,核心臟病學(xué)指導(dǎo)SCAD治療,對于SCAD患者, PCI較藥物保守治療未

10、見獲益,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 recommendation.cLevel of evidence.CAD=coronary

11、 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 fr

12、om myocardial revascularization vs. medical therapy among patients undergoing stress-rest myocardial perfusion scintigraphy. Eur Heart J 2011;32(8):1012 – 1024. 99. Optimal medical therapy with or without percutan- eou

13、s coronary intervention to reduce ischemic burden: results from the Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation (COURAGE) trial nuclear substudy. Circulation 2008;117(10):1283 – 1291. 1

14、43. 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 emi

15、ssion computed tomography. Circulation 2003;107(23):2900 – 2907. ….,,2014 ESC 血運(yùn)重建指南,,核心臟病學(xué)指導(dǎo)SCAD治療,,核心臟病學(xué)識(shí)別存活心肌,Int J Cardiol.2015 186():111-6,VIAMI trial：216例梗死區(qū)存在未行直接PCI的STEMI患者， 48～78h后行“冬眠心肌”檢查，隨機(jī)分為侵入治療組（n=106）和保守治

16、療組（n=110）,存在冬眠心肌的患者早期侵入治療較保守治療獲益更大,,核心臟病學(xué)識(shí)別存活心肌,Eur J Nucl Med Mol Imaging (2005) 32:430–437,253例既往MI并存在“冬眠心肌”的患者，分為血運(yùn)重建組（n＝142）和藥物治療組（n＝111）,15,This allows for accurate triage of patients by MPI for consideration of rev

17、ascularization. Patients without ischemia can be safely managed with optimal medical therapy.,核心臟病學(xué)指導(dǎo)CTO治療,,HCE=hard cardiac events,,J Nucl Cardiol 2013;20:563–8.,16,核心臟病學(xué)指導(dǎo)冠心病治療,,Matched,Unmatched（存活心?。?,17,冠狀動(dòng)脈微循環(huán)（尸檢）

18、,冠狀動(dòng)脈造影,核心臟病學(xué)在冠心病診斷中的應(yīng)用,,18,,Matched,Unmatched,核心臟病學(xué)評價(jià)冠心病預(yù)后,19,核心臟病學(xué)評價(jià)冠心病預(yù)后,,,,2010 ESC 血運(yùn)重建指南,Indications of different imaging tests for the diagnosis of obstructive CAD and for the assessment of prognosis in subjects

19、without known CAD,,aFor the prognostic assessment of known coronary stenosis, functional imaging is similarly indicated.,20,N=2,783Events=137,核心臟病學(xué)評價(jià)冠心病預(yù)后,,Circulation. 2011;124:2215-2224.,,Univariate predictors of card

20、iac death,采集時(shí)間長注射劑量相對高靈敏度相對低不能更早期發(fā)現(xiàn)疾病不能同時(shí)對多種核素顯像肥胖患者偽影嚴(yán)重?zé)o法絕對測定血流量和血流儲(chǔ)備,傳統(tǒng)的A-SPECT指導(dǎo)血運(yùn)重建有一定的局限性,,CZT改變了心臟核醫(yī)學(xué)的歷史,CZT半導(dǎo)體——新一代探測器,D-SPECT,更新?lián)Q代產(chǎn)品,D-SPECT 人工智能+機(jī)器人技術(shù) 開創(chuàng)心臟核醫(yī)學(xué)新歷程,以心臟為中心，追心掃描,Scan time: 49 secFWHM: 5

21、mm,Scan time: 600 secCollimator: LEGPFWHM: 11mm,A-SPECT,1 mm,D-SPECT,Co 57 線源,,-10,0,10,,,,190mm,新一代D-SPECT為指導(dǎo)冠心病診治提供新的可能,檢查時(shí)間: 10 倍掃描速度圖像質(zhì)量: 2 倍分辨率,Nuclear Medicine ＝ No Clear Medicine?,D-SPECT 2 Mins,傳統(tǒng)A-SPEC

22、T 25Mins,D-SPECT 不僅僅是快，而且已經(jīng)達(dá)到PET/CT的分辨率,,D-SPECT更精確、更精準(zhǔn),傳統(tǒng)SPECT的輻射劑量為： 9-15 mSv最新D-SPECT輻射劑量為： 1-3mSv ，檢查一次低于全年自然本底輻射水平??！,D-SPECT輻射劑量低、更安全,mSv 輻射劑量,D-SPECT 動(dòng)態(tài)掃描可以定量分析測得CFR,Coronary Flow Reserve （CFR）,? Measures integ

23、rated hemodynamic effects of epicardial CAD, diffuse atherosclerosis, vessel remodeling and microvascular dysfunction on myocardial tissue perfusion,Courtesy of Drs. Taqueti and Di Carli, Brigham and Wo

24、men’s Hospital,FFR與CFR大約40%的情況下存在不匹配,JACC.2012;5:193-202,冠脈造影管腔狹窄程度不能準(zhǔn)確反映冠脈血流儲(chǔ)備CFR,J AmColl Cardiol Img 2009;2:1009–23,Coronary Flow Reserve Associates With Risk Independent of Traditional Ischemia Measures,N= 2,783CD=

25、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 Car

26、diac Death in Diabetics,P=0.07,P=0.33,P=0.005,P=0.65,P=0.015,*Adjusted for Duke score, ischemia + scar, rest LVEF and early revascularization,N=2423CD=122,Source: Murthy VL, et al. Circulation. 2012;126:1858-1868,Corona

27、ry Flow Reserve, Revascularization, and Outcomes,Source: Taqueti VR, et al. Circulation 2015 Jan 6;131(1):19-27,? Only patients with angiographic obstruction AND low CFR seem to benefit for revasc, especially CABG,CFR in

28、 Prognosis and Therapy,,,OMT +/- Revasc,OMT,What is OMT?,Which Revasc Strategy?,,,Prognosis:,GOOD,POOR,Therapy:,,,Take Home Messages,核心臟病學(xué)對冠心病患者通過評估心肌缺血和心肌存活，對冠心病患者明確診斷，危險(xiǎn)分層，指導(dǎo)治療方案的制定和估測預(yù)后均有重要價(jià)值新一代D-SPECT的應(yīng)用為指導(dǎo)冠心病血運(yùn)用重建