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英国爱丁堡大学Alasdair J Gray团队研究了早期CT冠状动脉造影术对疑似急性冠状动脉综合征患者预后的影响。2021年9月29日出版的《英国医学杂志》发表了这项成果。

为了研究早期CT冠状动脉造影是否能改善急诊科急性胸痛、急性冠状动脉综合征及后续临床事件中危患者的一年临床预后，研究组在英国的37家医院进行了一项随机对照试验。招募怀疑或临时诊断为急性冠状动脉综合征、有一项或多项冠心病病史、心肌肌钙蛋白水平升高或心电图异常的成人患者，将其随机分组，分别接受早期CT冠状动脉造影和标准护理，或仅接受标准护理。主要终点是全因死亡或1年后继发的1型或4b型心肌梗死。

2015年3月23日至2019年6月27日，研究组共招募了1748名参与者，平均年龄为62岁，64%为男性，平均全球急性冠状动脉事件登记（GRACE）评分为115分，其中877例接受早期CT冠状动脉造影，871例仅接受标准护理。从随机分组到CT冠状动脉造影的中位时间为4.2小时。

CT冠状动脉造影组中有51名（5.8%）发生主要终点，仅标准护理组中有53名（6.1%），差异不显著。CT冠状动脉造影组中有474名（54.0%）患者接受了有创冠状动脉造影，显著低于仅标准护理组的530名（60.8%）。两组患者在冠状动脉血运重建、急性冠状动脉综合征药物治疗或后续预防性治疗方面没有总体差异。早期CT冠状动脉造影的中位住院时间为2.2天，略长于仅标准护理组的2.0天。

研究结果表明，对于患有急性胸痛和疑似急性冠状动脉综合征的中危患者，早期CT冠状动脉造影不会改变整体冠状动脉治疗干预或一年临床预后，但会降低有创性血管造影的发生率，同时适度增加住院时间。这些发现不支持在患有急性胸痛和疑似急性冠脉综合征的中危患者中常规使用早期CT冠状动脉造影。

附：英文原文

Title: Early computed tomography coronary angiography in patients with suspected acute coronary syndrome: randomised controlled trial

Author: Alasdair J Gray, Carl Roobottom, Jason E Smith, Steve Goodacre, Katherine Oatey, Rachel O’Brien, Robert F Storey, Nick Curzen, Liza Keating, Attila Kardos, Dirk Felmeden, Robert J Lee, Praveen Thokala, Steff C Lewis, David E Newby

Issue&Volume: 2021/09/29

Abstract:

Objectives To establish if the use of early computed tomography (CT) coronary angiography improves one year clinical outcomes in patients presenting to the emergency department with acute chest pain and at intermediate risk of acute coronary syndrome and subsequent clinical events.

Design Randomised controlled trial.

Setting 37 hospitals in the UK.

Participants Adults with suspected or a provisional diagnosis of acute coronary syndrome and one or more of previous coronary heart disease, raised levels of cardiac troponin, or abnormal electrocardiogram.

Interventions Early CT coronary angiography and standard of care compared with standard of care only.

Main outcome measures Primary endpoint was all cause death or subsequent type 1 or 4b myocardial infarction at one year.

Results Between 23 March 2015 and 27 June 2019, 1748 participants (mean age 62 years (standard deviation 13), 64% men, mean global registry of acute coronary events (GRACE) score 115 (standard deviation 35)) were randomised to receive early CT coronary angiography (n=877) or standard of care only (n=871). Median time from randomisation to CT coronary angiography was 4.2 (interquartile range 1.6-21.6) hours. The primary endpoint occurred in 51 (5.8%) participants randomised to CT coronary angiography and 53 (6.1%) participants who received standard of care only (adjusted hazard ratio 0.91 (95% confidence interval 0.62 to 1.35), P=0.65). Invasive coronary angiography was performed in 474 (54.0%) participants randomised to CT coronary angiography and 530 (60.8%) participants who received standard of care only (adjusted hazard ratio 0.81 (0.72 to 0.92), P=0.001). There were no overall differences in coronary revascularisation, use of drug treatment for acute coronary syndrome, or subsequent preventive treatments between the two groups. Early CT coronary angiography was associated with a slightly longer time in hospital (median increase 0.21 (95% confidence interval 0.05 to 0.40) days from a median hospital stay of 2.0 to 2.2 days).

Conclusions In intermediate risk patients with acute chest pain and suspected acute coronary syndrome, early CT coronary angiography did not alter overall coronary therapeutic interventions or one year clinical outcomes, but reduced rates of invasive angiography while modestly increasing length of hospital stay. These findings do not support the routine use of early CT coronary angiography in intermediate risk patients with acute chest pain and suspected acute coronary syndrome.

DOI: 10.1136/bmj.n2106

Source: https://www.bmj.com/content/374/bmj.n2106

BMJ-British Medical Journal:《英国医学杂志》，创刊于1840年。隶属于BMJ出版集团，最新IF：93.333
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