CAJ | 학술논문

目的：比较升级的Diamond-Forrester法(updated Diamond-Forrester method，UDFM)和Duke临床评分(Duke clinical score，DCS)对于冠心病的评估准确性，并进一步分析验前概率与冠脉CT造影(computed tomographic coronary angiography， CTCA)联合应用的诊断准确性。方法纳入2012年1月-2013年12月因稳定型心绞痛在解放军总医院心内科先后行CTCA和传统冠状动脉造影(conventional coronary angiography，CCA)的患者523例，分别用UDFM和DCS估算每例患者患冠心病的验前概率。以CCA结果为金标准，分析验前概率、CTCA及两者联合应用对冠心病的诊断准确性。理论验后概率根据贝叶斯公式进行计算。结果523例患者中有385例(74%)CCA结果为阳性。与UDFM相比，DCS将更多的CCA结果阳性患者分入高验前概率组(46%vs 23%，P＜0.0001)。DCS的ROC曲线下面积明显大于UDFM[0.77(0.73，0.82)vs 0.71(0.66，0.77)，P=0.0009]。根据DCS估算结果划分的低、中和高3个验前概率亚组中，CTCA的敏感性、特异性、阳性预测值及阴性预测值分别是94%、98%和97%，94%、87%和55%，91%、94%和93%及96%、96%和77%。中验前概率亚组的理论验后概率十分接近实际验后概率(阳性：94.7%vs 93.6%，阴性：3.7%vs 4.0%)。结论对于稳定型心绞痛患者，DCS比UDFM更适用于冠心病验前概率的估算。将按DCS估算的验前概率与CTCA联合应用，能够有效提高CTCA的诊断准确性，并避免过度检查。
목적：비교승급적Diamond-Forrester법(updated Diamond-Forrester method，UDFM)화Duke림상평분(Duke clinical score，DCS)대우관심병적평고준학성，병진일보분석험전개솔여관맥CT조영(computed tomographic coronary angiography， CTCA)연합응용적진단준학성。방법납입2012년1월-2013년12월인은정형심교통재해방군총의원심내과선후행CTCA화전통관상동맥조영(conventional coronary angiography，CCA)적환자523례，분별용UDFM화DCS고산매례환자환관심병적험전개솔。이CCA결과위금표준，분석험전개솔、CTCA급량자연합응용대관심병적진단준학성。이론험후개솔근거패협사공식진행계산。결과523례환자중유385례(74%)CCA결과위양성。여UDFM상비，DCS장경다적CCA결과양성환자분입고험전개솔조(46%vs 23%，P＜0.0001)。DCS적ROC곡선하면적명현대우UDFM[0.77(0.73，0.82)vs 0.71(0.66，0.77)，P=0.0009]。근거DCS고산결과화분적저、중화고3개험전개솔아조중，CTCA적민감성、특이성、양성예측치급음성예측치분별시94%、98%화97%，94%、87%화55%，91%、94%화93%급96%、96%화77%。중험전개솔아조적이론험후개솔십분접근실제험후개솔(양성：94.7%vs 93.6%，음성：3.7%vs 4.0%)。결론대우은정형심교통환자，DCS비UDFM경괄용우관심병험전개솔적고산。장안DCS고산적험전개솔여CTCA연합응용，능구유효제고CTCA적진단준학성，병피면과도검사。
Objective To compare the performance of updated Diamond–Forrester method (UDFM) and Duke clinical score (DCS) in patients with stable angina pectoris and assess the combined application of pre-test probability and computed tomographic coronary angiography (CTCA) in these patients. MethodsFive hundred and twenty-three symptomatic patients who underwent both CTCA and conventional coronary angiography (CCA) in 2 weeks in Chinese PLA General Hospital from January 2012 to December 2013 were enrolled in this study. The pre-test probability was determined using UDFM and DCS for each patient. Receiver operating characteristics (ROC) curves were used to compare two models. The diagnostic accuracy of CTCA for detecting coronary artery disease (CAD) was compared with CCA. The estimated post-test probability was calculated by Bayesian statistics.Results Of the 523 patients, 385 (74%) were positive tested by CCA. Compared with UDFM, DCS reclassified more positive patients into high group (46% for DCSvs. 23% for UDFM,P<0.000 1). The areas under ROC curves (AUC) for DCS was significantly greater than that for UDFM [0.77 (0.73, 0.82) vs 0.71 (0.66, 0.77), P=0.000 9]. In patient-based evaluation by CTCA, three pre-test probability groups according to DCS revealed a sensitivity of 94%, 98% and 97%, a specificity of 94%, 87% and 55%, a positive predictive value (PPV) of 91%, 94% and 93%, and a negative predictive value (NPV) of 96%, 96% and 77%, respectively. The estimated post-test probabilities corresponded well with the observed one, especially for the intermediate estimated pre-test probability group (positive: 94.7%vs 93.6%, negative: 3.7%vs 4.0%).Conclusion Compared with UDFM, DCS has a better performance in calculating pre-test probabilities in patients with stable angina pectoris. In addition, the combined application of DCS and CTCA can avoid unnecessary tests.