【作者】 徐妍；

【导师】 王智慧；

【作者基本信息】 吉林大学 ， 临床医学， 2011， 硕士

【摘要】 目的:研究冠脉256层CT对于冠状动脉斑块性质评估的准确性,评价其在冠状动脉病变诊断中的意义。方法:选择2009年12月至2010年12月入院行冠脉256层CT、CAG及IVUS检查的诊断为冠心病的病人。用IVUS检查结果评价256层CT对于冠状动脉病变检测的灵敏度(Se)、特异度(Sp)、阳性预测值(PPV)、阴性预测值(NPV)及对斑块性质的检测灵敏度。256层CT及IVUS对最小管腔面积、狭窄处血管外弹力膜面积、斑块面积、局部血管狭窄程度、重构指数、偏心指数进行测量比照,进一步评估二者的相关性。结果:以节段为基础比较256层CT、IVUS的检测:IVUS检查可见68处病变节段, 48处非病变节段。256层CT发现65处病变节段中IVUS检查证实63处。51处非病变节段中被IVUS证实47处。以节段为基础,256层CT对病变节段的检测灵敏度(Se)、特异度(Sp)、阳性预测值(PPV)、阴性预测值(NPV)分别为92.6%,97.9%、96.9%、92.2%。以斑块为基础,256层CT检测出16个软斑块、18个纤维型斑块、11个钙化型斑块。与IVUS对照,其灵敏度(Se)分别为72.7%、78.3%、91.7%。256层CT对最小管腔面积、狭窄处血管外弹力膜面积、斑块面积、局部血管狭窄程度、重构指数、偏心指数的测量分别为6.86±0.86mm2、15.36±2.45mm2、8.48±1.62mm2、58.6±9.67%、1.06±0.15、0.48±0.09,IVUS对其测量值分别为:5.63±0.89mm2、14.78±2.36mm2、9.16±1.83mm2、67.9±9.53%、1.09±0.16、0.52±0.07。二者测量结果p值均小于0.05,差异有统计学意义。但对于判断斑块的形态,256层CT及IVUS检查r值分别为0.79,0.83,0.88,0.68,0.82,0.87。结论:本研究表明:256层螺旋CT是一种安全、操作相对简便的冠状动脉全程无创检查方法,对于钙化病变有较高的诊断率,同时对冠状动脉粥样硬化病变敏感性较高,更具有特异性,对斑块的形态、性质的评估与IVUS有较高的相关性,可作为冠心病高危人群的普查筛选及支架术后、搭桥术后随访的评价依据。但其对非钙化型斑块的定性分析的可靠性仍受到质疑,同时它对操作者要求较高,需要年资较高,有多年丰富经验的检查者规范操作。检查过程中风险较低,但对于患者身体要求较高,频发房早、室早,房速,房颤,室速等心律失常患者不适合选择该项检查方法。第2部分冠脉血管超声评价冠脉造影判断临界病变及斑块性质的准确性的研究目的:研究并比较血管内超声对心绞痛症状典型但冠脉造影阴性的冠心病患者的诊断价值。方法:选择2009年12月至2010年12月住院的诊断为冠心病但冠脉造影病变为50-70%的病人,均行IVUS检查。对斑块的相关参数进行比照分析,对行PCI术的患者进行出院后的随访(再住院、心梗、死亡等)。结果:本研究中,定性研究发现:49例59处病变中偏心性斑块42例(71.19%),向心性斑块17例( 28. 81%),其中软斑块40例(67.80%),纤维型斑块9例(15.25%) ,钙化型斑块6例(10.17%) ,混合型斑块4例(6.78 %)。49例中1例发现血栓(2.04%)。定量研究发现:IVUS对59处斑块分别进行测量:平均最小管腔面积4.84±1.13mm2,平均EEMA 12.65±3.31mm2,平均斑块面积7.77±2.32mm2,平均管腔最小直径2.22±0.58mm,平均管腔最大直径2.74±0.7mm,平均斑块负荷61.08±11.66%。其中植入支架的病变处斑块测量值为:平均最小管腔面积3.51±0.94mm2,平均血管外弹力膜面积(EEMA) 11.94±2.08mm2 ,平均斑块面积8.42±1.63mm2 ,平均管腔最小直径1.87±0.24mm ,平均管腔最大直径2.32±0.36mm ,平均斑块负荷69.04±7.37%。冠脉造影检查病变处平均狭窄率56.4±5.6%,IVUS检查病变处斑块负荷61.08±11.66%,CAG低估了病变处的狭窄情况,低估了病变的危险性,二者结果比较差异有统计学意义(p =0.028<0.05)。结论:对于临床上心绞痛症状典型,但冠脉造影为临界病变的患者应提高重视程度,冠脉造影低估了病变处的狭窄情况,低估了病变的危险性,建议进一步行血管内超声检查,以准确评估狭窄程度及斑块性质,对于不稳定病变可在IVUS指导下行PCI治疗,以减少斑块破裂所致恶性的心血管事件的发生的几率。更多还原

【Abstract】 Objective:To study the accuracy assessment of 256- layer CT in evaluating coronary plaque and evaluate in the diagnosis of coronary artery disease.Methods:The patients with CHD from December 2009 to December 2010. 256- layer CT, CAG and IVUS were performed in every patient. IVUS evaluates the diagnostic sensitivity (Se), specificity (Sp), positive predictive value (PPV), negative predictive value (NPV) and the detection sensitivity (Se) of plaques properties of 256- layer CT. 256 CT and IVUS to MLA, EEMA, the average plaque area, the partial angiostenosis degree, RI, EI carry on the survey according to, further appraises the their relevance.Results:Comparison of segment-based 256- layer CT, IVUS detection: IVUS found 68 lesion segments, 48 non-lesion segments. 256- layer CT found 65 lesion segments, IVUS examination confirmed 63. In 51 non-lesion segments, 47 were confirmed by IVUS. On the segment basis, the sensitivity (Se), specificity (Sp), positive predictive value (PPV), negative predictive value (NPV) of 256-layer CT was 92.6%, 97.9%, 96.9% 92.2%. On the plaque basis, 256- layer detected 16 soft plaque, 18 fibrous plaque, 11 calcified plaques. Compared with IVUS, the sensitivity (Se) were 72.7% and 78.3%, 91.7%. 256 CT to MLA, EEMA, the average plaque area, the partial angiostenosis degree, RI, EI measurements: 6.86±0.86mm2,15.36±2.45mm2,8.48±1.62mm2, 58.6±9.67%,1.06±0.15,0.48±0.09,IVUS measurements: 5.63±0.89mm2, 14.78±2.36 mm2, 9.16±1.83mm2,67.9±9.53%,1.09±0.16,0.52±0.07。The two measurement result p value is smaller than 0.05, the difference has statistics significance. But regarding the judgment mottling’s shape, 256 CT and IVUS inspects the r value respectively is 0.79,0.83,0.88,0.68,0.82,0.87.Conclusion:This study shows that: 256-layer spiral CT is a safe, simple and noninvasive method in all coronary, the calcification has a high diagnostic rate,on coronary atherosclerosis higher sensitivity, more specific, the shape of the plaque, and IVUS assessment of the nature of a higher correlation at high risk of coronary artery disease as non-invasive screening and stenting Census , bypass means for postoperative follow-up. But its non-calcified plaque in the reliability of qualitative analysis is still being questioned, while its operators are higher, and requires years of high, has many years experience in inspection of the standard operation. Lower risk during the examination, but for the patient’s body are higher, and frequent atrial premature, ventricular premature beats, atrial tachycardia, atrial fibrillation, ventricular tachycardia and other arrhythmias in patients not suitable for selection of the screening method. Part two: The coronary intravascular ultrasound evaluation of coronary angiography to determine the critical nature of disease and the accuracy of plaque.Objective:To study and compare the coronary intravascular ultrasound of the typical symptoms of angina but coronary angiography in patients with negative value.Methods:The hospitalization from December 2009 to December 2010 who diagnosed coronary heart disease but the coronary angiography for 50-70% of patients, do IVUS examination. To patch the plaque morphology,nature, location and degree of stenosis were analyzed, the stent patients discharged were follow-up (myocardial infarction, hospitalization, death, etc.).Results:In this study, qualitative research found that: 49 patients with 59 lesions and eccentric plaques in 42 patients (71.19%), concentric plaque in 17 patients (28.81%), of which 40 cases of soft plaque (67.80%) , fiber-type plaques in 9 cases (15.25%), calcified plaque in 6 cases (10.17%), mixed plaque in 4 cases (6.78%). Found 49 cases of thrombosis in 1 patient (2.04%). Quantitative research found that: IVUS plaque of 59 separate measurements: the average minimum lumen area 4.84±1.13mm2, average EEMA 12.65±3.31mm2, the average plaque area 7.77±2.32mm2, the average minimum lumen diameter 2.22±0.58mm, The average maximum lumen diameter 2.74±0.7mm, mean plaque burden 61.08±11.66%. In which the lesion stent plaque is measured: the average minimum lumen area 3.51±0.94mm2, average EEMA 11.94±2.08mm2, the average plaque area 8.42±1.63mm2, the average minimum lumen diameter 1.87±0.24mm, the average maximum lumen diameter 2.32±0.36mm, the average plaque burden 69.04±7.37%. The average coronary angiography lesion stenosis was 56.4±5.6%, IVUS examination the lesion plaque burden 61.08±11.66%, CAG lesions underestimated the stenosis, the risk of underestimating the disease, the difference was between the two results significance (p = 0.028 <0.05). Conclusion:The clinical symptoms of typical angina pectoris, coronary arteriography lesions underestimated the stenosis, the risk of underestimating the disease, coronary arteriography in patients with critical lesions should be further intravascular ultrasound to accurately assess the degree of stenosis and plaque, for unstable lesions can be down in the IVUS guided PCI treatment, to reduce the rate of plaque rupture lead to serious cardiovascular events.更多还原