Overview with Meta-analysis of Systematic Reviews of the Diagnostic and Prognostic Value of Coronary Computed Tomography Angiography in the Emergency Department

Abstract Background: The high prevalence of CAD, as well as your impact on health expenditure and the various treatment options to reduce morbidity and mortality related to CAD, comes to develop a diagnostic tool precis and with important findings in the Emergency Department. Objetive: To conduct an overview with meta-analysis to compile evidence from multiple systematic reviews (SR) on the diagnostic and prognostic value of coronary computed tomography angiography (CCTA) to assess acute chest pain in the emergency department (ED). Methods: We included SR of primary studies that evaluated the diagnostic and prognostic value of CCTA ≥ 64 channels in the ED. The studies were conducted in patients at low and intermediate risk for coronary artery disease (CAD). Quality assessment was performed using PRISMA and approved reviews that scored ≥ 80%. Two authors independently extracted data using a standardized form. Spearman correlation test, Chi-square test, Cochran's Q test or Higgins and Thompson statistical I2 were used. For meta-analysis, "mada" package statistical software R Core Team, 2015, was used. The significance level adopted was 95%. Results: Four reviews were eligible for inclusion in this overview, resulting in 13 articles after applying the exclusion criteria, and only 10 of these were used for meta-analysis, adding up to a total of 4831 patients (mean age, 54 ± 6 years; 51% male), of whom 46% were hypertensive, 32% had dyslipidemia, 13% had diabetes and 26% had a family history of premature CAD. In the meta-analysis, 9 studies defined CCTA positive in the presence of luminal lesions ≥ 50%, while 1 study defined it as luminal lesions ≥ 70%. Sensitivity ranged from 77% to 98%, and specificity, from 73% to 100%. The univariate analysis showed homogeneity of diagnostic odds ratio (DOR) [Q = 8.5 (df = 9), p = 0.48 and I2 = 0%]. The pooled mean DOR for CCTA in primary analyses was 4.33 (95% CI: 3.47 - 5.18). The area under the curve (AUC) was 0.982 (95% CI: 0.967 - 0.999). There was no death, 29 (0.6%) infarcts, 92 (1.9%) revascularizations and 312 (6.4%) invasive coronary angiographies. The diagnosis of acute coronary syndrome occurred in 7.3% of the 1655 patients included in the meta-analysis. Conclusions: The use of CCTA as a tool for stratification of patients at low or intermediate cardiovascular risk, who are in the ED with chest pain, has high accuracy, safety, reduces length of hospital stay and probably the costs, producing an early diagnosis and more effective decision making. (Int J Cardiovasc Sci. 2017; [online].ahead print, PP.0-0)

摘要 背景：冠状动脉粥样硬化性心脏病（Coronary Artery Disease, CAD）具有高患病率，其对医疗开支的影响，以及诸多可降低CAD相关发病率与死亡率的治疗方案，使得开发一款能在急诊科得出可靠结论的精准诊断工具成为迫切需求。
目标：本研究旨在开展一项包含元分析的伞状综述，整合多项系统评价（Systematic Review, SR）中关于冠状动脉计算机断层血管造影（Coronary Computed Tomography Angiography, CCTA）在急诊科（Emergency Department, ED）用于急性胸痛评估的诊断与预后价值的证据。
方法：我们纳入了针对急诊科中≥64排CCTA诊断及预后价值开展的原始研究的系统评价。纳入研究的受试者为冠状动脉疾病低、中危患者。采用PRISMA声明对纳入文献进行质量评价，筛选评分≥80%的综述。由2名研究者独立采用标准化数据提取表提取数据。统计分析采用Spearman相关检验、卡方检验、Cochran Q检验或Higgins与Thompson的I²统计量。元分析采用R Core Team 2015年开发的"mada"软件包完成，检验水准设定为95%。
结果：共有4篇综述符合纳入标准，经排除标准筛选后剩余13篇文献，其中10篇用于元分析，合计纳入4831例患者（平均年龄54±6岁；男性占比51%），46%的患者合并高血压、32%存在血脂异常、13%患有糖尿病、26%有早发CAD家族史。元分析中，9项研究将管腔狭窄≥50%定义为CCTA阳性，1项研究将该阈值设定为管腔狭窄≥70%。其灵敏度范围为77%~98%，特异度范围为73%~100%。单因素分析显示诊断比值比（Diagnostic Odds Ratio, DOR）具有同质性[Q=8.5（自由度df=9），p=0.48，I²=0%]。初始分析中CCTA的合并DOR为4.33（95%置信区间：3.47~5.18）。受试者工作特征曲线下面积（Area Under the Curve, AUC）为0.982（95%置信区间：0.967~0.999）。研究中未出现死亡病例，共发生29例（0.6%）梗死、92例（1.9%）血运重建、312例（6.4%）有创冠状动脉造影。纳入元分析的1655例患者中，7.3%被诊断为急性冠脉综合征（Acute Coronary Syndrome, ACS）。
结论：将CCTA用于急诊科急性胸痛就诊的低、中危心血管风险患者的分层评估，具有较高的诊断准确性与安全性，可缩短住院时长并可能降低医疗成本，实现早期诊断与更高效的临床决策。（《国际心血管科学杂志》2017年；[网络版预印]，页码0-0）