衰減校正心肌灌注掃描做為疑似冠狀動脈心臟病患者之診斷與預後工具

Attenuation Corrected Myocardial Perfusion Imaging as the Diagnostic and Prognostic Tool in Patients with Suspected Coronary Artery Disease

黃潔宜(Jei-Yie Huang)

指導教授 ： 簡國龍

國立臺灣大學/公共衛生學院/流行病學與預防醫學研究所/博士(2022年)

https://doi.org/10.6342/NTU202200054

摘要

背景與目的：心肌灌注掃描（MPI）是良好的冠狀動脈心臟病診斷工具，也經常被用於預測冠狀動脈心臟病的預後。然而，心肌灌注掃描的完整潛力還有部分未知，這多由於假影造成，其中之一即為衰減假影(attenuation artifact)。在此研究中（1）我們想了解衰減校正是否以及如何改善心肌灌注掃描在不同冠狀動脈供應區域的診斷性能；（2）評估心肌灌注掃描的診斷表現，比較有無電腦斷層攝影衰減校正的差異；（3）評估心肌灌注掃描的預後價值，比較有無電腦斷層攝影衰減校正的差異。
方法：（1）採用系統回顧與統和分析策略來確定衰減校正是否以及如何改善不同冠狀動脈區域的診斷性能。（2）以橫斷面研究，比較有無電腦斷層攝影衰減校正之心肌灌注掃描的診斷表現。診斷表現以敏感性，特異性，接收者操作特徵曲線(receiver operating characteristic curve)及曲線下面積呈現，且做兩組之間比較。（3）以回顧性世代研究，比較有無電腦斷層攝影衰減校正之心肌灌注掃描的預後價值。主要指標為全死因死亡率。以Kaplan-Meier存活曲線和Cox比例風險分析，辨識顯著因素。
結果：（1）統合分析共納入22筆研究，衰減校正可增進診斷右冠狀動脈狹窄的特異性，無論是電腦斷層衰減校正或是放射性核種衰減校正的次群組分析皆呈現此結果。而比較敏感性時，衰減校正的有無無法造成統計上之顯著差異。同樣地，對於診斷左前降支與迴旋支冠狀動脈狹窄的診斷，不受衰減校正而改變。（2）自2008年1月至2009年6月，世代研究中總共連續收案了108位符合收案條件的患者。合併電腦斷層衰減校正之心肌灌注掃描可藉由增進特異性、不降低敏感性，進而增進診斷冠狀動脈心臟病之診斷表現。偵測血管狹窄時，電腦斷層衰減校正可顯著增進偵測左前降支與迴旋支冠狀動脈狹窄之診斷，然對於偵測右冠狀動脈狹窄僅提供一點點進步。（3）對於心肌灌注掃描之預後價值，本研究發現：使用適切切點之總壓力評分(SSS)或總休息評分(SRS)，無論是有衰減校正或是無衰減校正之心肌灌注掃描皆可發現顯著的存活差異。無論是有衰減校正或是無衰減校正之心肌灌注掃描，可發現總壓力評分與總休息評分為預測全死因死亡與全死因死亡合併心血管相關住院之獨立預後因子。
結論：此統合分析建議衰減校正應應用於心肌灌注掃描，以增進診斷右冠狀動脈狹窄。電腦斷層衰減校正藉由提升特異性，顯著提升診斷冠狀動脈心臟病之診斷表現，此提升於肥胖與男性患者身上尤為顯著。於預後價值上，衰減校正有無之心肌灌注掃描呈相似價值，總壓力評分與總休息評分為預測全死因死亡與全死因死亡合併心血管相關住院之獨立預後因子。總結來說，我們建議衰減校正應常規使用到心肌灌注掃描，以增進冠狀動脈心臟病診斷之確定性，與協助患者疾病預後之預測。

關鍵字

心肌灌注掃描 ； 衰減校正 ； 冠狀動脈心臟病 ； 統合分析 ； 診斷 ； 預後

並列摘要

Background and Objectives: Myocardial perfusion imaging (MPI) is well established diagnostic tool for coronary artery disease (CAD) and is also often used for predicting outcome of CAD. However, the full potential of MPI has not been realized due to artifacts, such as attenuation. In this study, (1) we want to understand whether and how attenuation correction (AC) improved diagnostic performance of MPI in different coronary territories, (2) evaluate the diagnostic performance of MPI with and without computed tomography (CT) attenuation correction (AC) and (3) evaluate the prognostic value of MPI with and without CTAC.
Methods: (1) Systemic review and meta-analysis strategy were used to determine whether and how AC improved diagnostic performance of MPI in different coronary territories. (2) We conducted a cross-sectional study for evaluating diagnosis performance of MPI, comparing CTAC with non-AC(NAC). Diagnostic performance was presented in sensitivity, specificity, receiver operating characteristic curve with area under curve (AUC) and compared between two groups. (3) We conducted a retrospective cohort study for evaluating the prognostic value of MPI, comparing CTAC with NAC. The primary study endpoint was all-cause mortality. Kaplan-Meier curves and Cox proportional hazards analysis were done to for identifying the significant factors.
Results: (1) A total of 22 studies were included in the meta-analysis. AC significantly improved the specificity of detecting RCA disease compared with NAC and also in the CTAC versus NAC and RAC versus NAC subgroups. However, no significant differences were noted when comparing sensitivity. In addition, there was no significant change in the diagnostic performance after AC for LAD and LCX stenosis. (2) From January 2008 to June 2009, 108 consecutive patients who met our inclusion criteria were included into our cohort. The combination of CTAC images led to significant improvements in diagnostic performance when diagnosing CAD at the patient level, by improving specificity without reducing sensitivity. When diagnosing single vessel stenosis, CTAC images significantly improved diagnostic performance when detecting LAD and LCX stenosis, but only slightly improved diagnostic performance when evaluating RCA. (3) Regarding to the prognostic value of MPI, with a proper cutoff value of summed stress score (SSS) or summed rest score (SRS) (SSS 13 for AC, SSS 16 for NAC, SRS 6 for both AC and NAC), there were significant differences in survival in both AC and NAC images. SSS and SRS showed similar independent predictive values in predicting all-cause mortality and composite of all-cause mortality plus CV-related re-admission, in both AC and NAC MPI.
Conclusions:
Our meta-analysis suggested that AC should be applied to MPI to improve the diagnosis of CAD, and that AC MPI can improve the specificity of detecting RCA stenosis. Regarding to diagnostic value, CTAC significantly improved diagnostic performance primarily by increasing the specificity, and the improvements were significantly greater in obese patients and male patients. Regarding to prognosis, both CTAC and NAC 201Tl MPI showed similar values. SRS with or without AC were significant predictors for all-cause mortality. SSS and SRS with or without AC were the only significant predictors for the composite of all-cause mortality and CV events in this study. Consequently, we suggested that AC should be applied to MPI as routine clinical practice.

並列關鍵字

myocardial perfusion imaging ； attenuation correction ； coronary artery disease ； meta-analysis ； diagnostic tool ； prognostic tool

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