Publication: Diagnóstico de cardiopatía isquémica en pacientes de riesgo intermedio: utilidad combinada de la tomografía computarizada coronaria y la resonancia magnética cardíaca
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2015-04-22
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Universidad Complutense de Madrid
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Abstract
La cardiopatía isquémica de origen coronario es la primera causa de muerte en la población española y tiene un impacto sustancial en el gasto sanitario, por lo que su diagnóstico precoz y preciso es crítico. La angiografía coronaria convencional ha sido la técnica estándar de estudio, pues permite en un solo acto detectar y tratar las estenosis vasculares significativas (que disminuyen al menos un 50 % el diámetro luminal). Sin embargo, no estima las consecuencias hemodinámicas de las lesiones aterosclerosas sobre el miocardio y, al tratarse de un procedimiento invasivo, puede tener complicaciones. En los últimos años, la tomografía computarizada multicorte coronaria y la resonancia magnética cardiaca de estrés se han posicionado como alternativas incruentas para evaluar la enfermedad isquémica coronaria estable.
El objetivo de este estudio fue evaluar de forma prospectiva la capacidad de ambos métodos comparados con la coronariografía invasiva para diagnosticar lesiones arteriales epicárdicas funcionalmente relevantes en una cohorte de 60 pacientes sintomáticos con probabilidad intermedia de padecer la enfermedad e, indirectamente, identificar a quienes no precisaban un cateterismo, con sus implicaciones clínicas y económicas.
Los resultados del trabajo muestran que el rendimiento de dicha combinación es comparable al de la angiografía convencional, especialmente para descartar isquemia coronaria (especificidad y valor predictivo negativo mayores del 90 %), a un coste inferior y sin compromiso clínico a corto-medio plazo, por lo que podría reemplazarla en el análisis inicial de la población de riesgo intermedio con clínica sospechosa estable y pruebas de esfuerzo equívocas. No obstante, hacen falta ensayos más amplios que validen las indicaciones y el coste-efectividad de estos procedimientos como estrategia de detección sistemática en la práctica habitual.
Ischemic heart disease is the leading cause of death in the Spanish population and has a substantial impact on health care expenditure; thus, accurate and prompt diagnosis is critical. Coronary angiography has been the standard reference for diagnosis, permitting simultaneously the detection and treatment of significant coronary artery stenoses (those narrowing 50% or more the luminal diameter). However, this technique is not capable of estimating the hemodynamic consequences of atherosclerosis on the myocardium and, being an invasive procedure, there are risks associated with it. In recent years, fast coronary computed tomography angiography and perfusion cardiac magnetic resonance imaging have emerged as noninvasive alternatives to evaluate stable symptoms suspicious for ischemic coronary disease. This study was conducted in a cohort of 60 individuals at intermediate pretest likelihood of disease to prospectively determine the accuracy of both imaging techniques compared with conventional angiography in the assessment of functionally relevant coronary artery stenoses, and to indirectly identify those in whom an elective catheterization could be safely avoided, with its clinical and economic implications. The results of the analysis show a comparable diagnostic performance of the aforementioned combination versus coronary angiography, especially to rule out significant coronary artery disease (specificity and negative predictive value over 90%), at less cost, and with no health impairment in the near-, mid-term horizon. In this way, it could replace the invasive strategy in the initial evaluation of intermediate-risk population with stable chest pain and equivocal exercise tests. Nevertheless, further research is needed that validate the appropriate role and cost-effectiveness of these procedures as a screening method in the outpatient setting
Ischemic heart disease is the leading cause of death in the Spanish population and has a substantial impact on health care expenditure; thus, accurate and prompt diagnosis is critical. Coronary angiography has been the standard reference for diagnosis, permitting simultaneously the detection and treatment of significant coronary artery stenoses (those narrowing 50% or more the luminal diameter). However, this technique is not capable of estimating the hemodynamic consequences of atherosclerosis on the myocardium and, being an invasive procedure, there are risks associated with it. In recent years, fast coronary computed tomography angiography and perfusion cardiac magnetic resonance imaging have emerged as noninvasive alternatives to evaluate stable symptoms suspicious for ischemic coronary disease. This study was conducted in a cohort of 60 individuals at intermediate pretest likelihood of disease to prospectively determine the accuracy of both imaging techniques compared with conventional angiography in the assessment of functionally relevant coronary artery stenoses, and to indirectly identify those in whom an elective catheterization could be safely avoided, with its clinical and economic implications. The results of the analysis show a comparable diagnostic performance of the aforementioned combination versus coronary angiography, especially to rule out significant coronary artery disease (specificity and negative predictive value over 90%), at less cost, and with no health impairment in the near-, mid-term horizon. In this way, it could replace the invasive strategy in the initial evaluation of intermediate-risk population with stable chest pain and equivocal exercise tests. Nevertheless, further research is needed that validate the appropriate role and cost-effectiveness of these procedures as a screening method in the outpatient setting
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Tesis inédita de la Universidad Complutense de Madrid, Facultad de Medicina, Departamento de Medicina, leída el 17-11-2014