杨立-心脏CT检查适应征和降低辐射剂量共识

DepartmentofRadiology,PLAGeneralHospital心脏CT检查（CCT)共识认识解放军总医院放射科杨立DepartmentofRadiology,PLAGeneralHospital正常冠状动脉DepartmentofRadiology,PLAGeneralHospital正常冠状动脉DepartmentofRadiology,PLAGeneralHospital左冠经交通支与右冠相连DepartmentofRadiology,PLAGeneralHospital2010AppropriateUseCriteriaforCCTDepartmentofRadiology,PLAGeneralHospitalTheAimofguidelineDepartmentofRadiology,PLAGeneralHospitalGuideline起草团队CardiacComputedTomographyWritinGroup7peopleOfficialAmericanCollegeofCardiologyFoundationRepresentative;OfficialAmericanSocietyofNuclearCardiologyRepresentative;OfficialSocietyforCardiovascularAngiographyandInterventionsRepresentative;OfficialSocietyofCardiovascularComputedTomographyRepresentative;OfficialAmericanHeartAssociationRepresentative;OfficialAmericanCollegeofRadiologyRepresentative;OfficialNorthAmericanSocietyforCardiovascularImagingRepresentativeDepartmentofRadiology,PLAGeneralHospitalGuideline起草团队TechnicalPanel19peopleOfficialAmericanSocietyofEchocardiographyRepresentative;OfficialSocietyforCardiovascularMagneticResonanceRepresentative;OfficialAmericanCollegeofEmergencyPhysiciansRepresentative;OfficialHeartRhythmSocietyRepresentative;OfficialHealthPlanRepresentative;OfficialAmericanCollegeofPhysiciansRepresentativeDepartmentofRadiology,PLAGeneralHospital基本概念Anappropriateimagingstudyisoneinwhichtheexpectedincrementalinformation,combinedwithclinicaljudgment,exceedstheexpectednegativeconsequences*byasufficientlywidemarginforaspecificindicationthattheprocedureisgenerallyconsideredacceptablecareandareasonableapproachfortheindication.（适应征或成像检查）适当是指，针对某一特定指征，通过该项检查并与临床资料结合，所获得的增量信息远远超过可能遇见的负面结果，方被认为是合理、可接受的。DepartmentofRadiology,PLAGeneralHospital检查合适程度评分Score7to9:Appropriatetestforspecificindication(testisgenerallyacceptableandisareasonableapproachfortheindication).Score4to6:Uncertainforspecificindication(testmaybegenerallyacceptableandmaybeareasonableapproachfortheindication).(Uncertaintyalsoimpliesthatmoreresearchand/orpatientinformationisneededtoclassifytheindicationdefinitively.)Score1to3:Inappropriatetestforspecificindication(testisnotgenerallyacceptableandisnotareasonableapproachfortheindication).DepartmentofRadiology,PLAGeneralHospital冠心病风险分级DepartmentofRadiology,PLAGeneralHospital冠心病风险分级DepartmentofRadiology,PLAGeneralHospital冠心病风险分级DepartmentofRadiology,PLAGeneralHospital适应征分类Guidelines对以下7个方面CCT检查适当与否的分级评价DepartmentofRadiology,PLAGeneralHospital1.DetectionofCADinSymptomaticPatientsWithoutKnownHeartDisease无心脏病史而有症状时，CCT仅用于中等以下风险人群CTA适应症评分等级DepartmentofRadiology,PLAGeneralHospitalCTA适应症评分等级2.DetectionofCAD/RiskAssessmentinAsymptomaticPatientsWithoutKnownCAD无冠心病史、无症状者，CCT检查基本上不合适或价值不清DepartmentofRadiology,PLAGeneralHospitalCTA适应症评分等级3.DetectionofCADinOtherClinicalScenarios有心脏病史而心功能减低时和非心脏手术且中等风险的术前评价DepartmentofRadiology,PLAGeneralHospitalCTA适应症评分等级：既往心脏检查DepartmentofRadiology,PLAGeneralHospitalCTA适应症评分等级5.RiskAssessmentPreoperativeEvaluationofNoncardiacSurgeryWithoutActiveCardiacConditionsDepartmentofRadiology,PLAGeneralHospitalCTA适应症评分等级6.RiskAssessmentPostrevascularization(PCIorCABG)CCT用于有症状的CABG和支架置入后，无症状且支架≥3mmDepartmentofRadiology,PLAGeneralHospitalCTA适应症评分等级7.EvaluationofCardiacStructureandFunction(1)心脏功能评价，不适合首选CCT检查，其他检查不能进行时，可应用CCTDepartmentofRadiology,PLAGeneralHospitalCTA适应症评分等级7.EvaluationofCardiacStructureandFunction(2)怀疑心脏肿物或血栓，不适合首选CCT，其他检查不适合时，可选CCT检查DepartmentofRadiology,PLAGeneralHospital发现冠脉病变心脏检查合适适应症：（评分在7分以上）无心脏疾患、但有非急性心肌缺血症状症状，特别是中度风险者无心脏疾患、但临床症状提示急性冠脉综合征者对无症状、无冠脉病史者，可行冠脉钙化积分检查无冠脉病史、新出现心衰（左心室功能受损，低、中度风险者）非心脏手术、术前冠脉评估-中度风险者正常心电图但症状持续存在者和平板运动试验提示中度风险者DepartmentofRadiology,PLAGeneralHospital发现冠脉病变心脏检查合适适应症：（评分在7分以上）心电图负荷试验和影像检查结果矛盾者或负荷试验结果不明有症状且钙化积分检查400以下既往负荷试验正常，但新出现症状或症状加重CABG术后，出现新心肌缺血症状PCI术后无症状，左主干≥3mmStent冠脉和其他胸部血管解剖异常和成人复杂先心病心梗或心衰后，其他检查效果不明时左室功能检查、右室功能和心律不齐性右室发育异常或右室形态DepartmentofRadiology,PLAGeneralHospital发现冠脉病变心脏检查合适适应症：（评分在7分以上）心脏内外邻近结果的评价：其他方法结果不明时，行瓣膜、人工瓣膜、肿物、心包周围结构、肺静脉、冠状静脉、CABG、内乳动脉等检查DepartmentofRadiology,PLAGeneralHospital心脏检查不恰当适应症：（评分在3分以下）DepartmentofRadiology,PLAGeneralHospitalDepartmentofRadiology,PLAGeneralHospitalDepartmentofRadiology,PLAGeneralHospital心脏检查不恰当适应症：（评分在3分以下）无病史、无症状（钙化积分和CTA），中、低风险人群有症状、同时高风险人群，明确心梗者高风险人群、心脏术前评价；非心脏手术、没有活动性心脏疾患、外科手术为低风险既往检查明确或否定冠脉病变、无症状者，两年之内的重复检查支架≤3mm、CABG术后5年，无症状者心脏结构和功能、肿物首选检查DepartmentofRadiology,PLAGeneralHospital认识并体会Guideline：指引（启示、指导）；（指南：guide）Guideline从临床应用角度，客观评价CCT的应用价值和限度Guideline为CCT临床应用和研究提供启发和思路DepartmentofRadiology,PLAGeneralHospital认识体会Guideline内容较复杂，使用较繁琐与其认为是临床使用指南、不如说是心脏检查研究结果综述和发展方向提示DepartmentofRadiology,PLAGeneralHospital中国专家共识一、开展心脏冠状动脉CT检查对操作者能力培训的基本要求：对临床医师的要求和对医师培训的要求：放射科医师独立从事心脏CT临床诊断工作，必须具有执业医师资格和大型设备上岗证(CT)；必须了解心脏冠状动脉检查适应证；接受不同等级的培训(表1)，其中中级和高级水平以上方可独立操作和书写诊断报告。DepartmentofRadiology,PLAGeneralHospital上岗人员基本培训要求DepartmentofRadiology,PLAGeneralHospital扫描及降低剂量方案心脏冠状动脉CT扫描的技术操作要求(一)推荐使用的标准化冠状动脉检查方案：患者准备、CCA对心率的要求、心率控制、心率不齐情况下的处理、扫描前硝酸甘油的应用、对比剂注射方案、钙化积分扫描方案、CCA扫描方案、图像重建和后处理方案、图像摄片和后处理方案(二)推荐使用的放射线剂量控制方案：降低辐射剂量最常用的有效方法：(1)管电流调制(2)前置滤线器(3)降低管电压(4)前瞻性心电门控采集技术DepartmentofRadiology,PLAGen