Udo Sechtem教授 2013稳定性冠心病指南主席

　　<International Circulation> : The new ESC guidelines on stable coronary artery disease has just been presented.  What do you think are the most important changes from the previous version?

　　Professor Sechtem :Well， the diagnostic algorithm is now based on pretest probability It is also new that the pretest probability should be determined from a new set of data， which is recent and not from the old guideline. In the previous guidelines of the ESC and the US guidelines of 2012 the data was from 1979. The new data show that the prevalence of coronary stenosis has decreased over the years in patients with stable angina. Instead functional coronary disease such as microvascular angina has become more frequent. Thus we now stress the importance of functional disease， microvascular disease and coronary vasospasm much more throughout the text. Finally we， discuss for the first time in detail the role of new imaging techniques such as MRI and coronary CTA.

　　<International Circulation> : Talking about pretest probability， the value of diagnostic tests is closely related to pretest probability and to decide the pretest probability， it is somewhat arbitrary…Professor Sechtem ( 1:49 – 2:05 ) : It is not arbitrary， there is a large dataset and depending on your symptoms， your age and your sex， you have a certain pretest probability.

　　<International Circulation> : So actually it is based on data.  What do you think about the role of coronary CTA for diagnosis and where does coronary CTA stand in the hierarchy of all those diagnostic tests?

　　Professor Sechtem :Coronary CTA has become an interesting new player but we need to be aware of the fact that it is a very narrow window of pretest probabilities in which coronary CTA makes sense. If the pretest probability is low， then you are dealing with women usually， young women， and you do not want to send them to coronary CTA because of the radiation.  When you deal with patients who have a high pretest probability， you are dealing with the problem of calcification and if there is a lot of calcium， everything looks terrible on CCTA. This makes you think the patient has stenoses but when you do an invasive angiogram there is no stenosis. These two extremes illustrate the limitations of CCTA.

　　<International Circulation> : What do you think is the best patient suitable for the CCTA test?

　　Professor Sechtem :Well， the best patient is， lets say a 40 to 45 year-old man who has atypical symptoms. Such patients often have invasive coronary angiography. Instead， a high quality coronary CTA could be used to exclude relevant epicardial coronary disease. If he has disease at a prognostically relevant site or sites， then of course he will undergo invasive coronary angiography afterwards with the aim of revascularization.

　　<International Circulation > : So it is quite a sensitive topic.  The other question is about revascularization and the optimal medical therapy.  Do you think this new guidelines give a clear answer on this question?

　　Professor Sechtem :I think the answer can only be as clear as the data.  Bernhard Gersh made it very clear in our text， how the symptoms of the patient and the extent of ischemia and coronary anatomy play together in making the right decision.

　　<International Circulation> : What is your approach in your clinical practice?

　　Professor Sechtem :Well we go with the guidelines.

　　<International Circulation> :  What might change in the future?

　　Professor Sechtem : Guidelines are a moving target.  We have will have a revascularization guideline coming out next year which will look at the same questions from a different angle and may - with the inclusion of new data - come to somewhat different conclusions. Thus， you will have to do the same interview next year again..

　　2013版新指南的亮点

　　2013 ESC稳定性冠心病管理指南的焦点是诊断和危险分层。其中，根据验前概率（pre-test probability）选择检查方法是首次引入的概念，同样评估验前概率的数据集也是最新的。新数据显示，稳定型心绞痛患者的狭窄患病率呈下降趋势。验前概率的评估基于最新的大型数据集，根据患者性别、年龄和症状，决定验前概率大小。新指南另一亮点是强调功能性疾病、微血管疾病和冠状血管痉挛的重要性。

　　CCTA在稳定性冠心病诊断中的地位

　　指南首次探讨新影像学技术如磁共振成像和冠状动脉CT血管造影（CCTA）的作用。CCTA是一种令人兴奋的新手段，但我们必须意识到这一检查的窗口很狭窄。如果验前概率很低，如年轻女性，因为放射线的缘故应避免对她们进行CCTA检查。如果验前概率非常高，意味着钙化非常严重，而非常严重的钙化导致CCTA图像类似严重狭窄，并进而实施血管造影，却发现没有狭窄。这些是CCTA的不足之处。适合CCTA检查的最佳患者类型是40～45岁的男性，症状不典型，至少在德国这类患者将进行血管造影。如果先进行高质量CCTA检查，结果正常，可使其免于侵入性检查。如果CCTA发现异常，患者当然将进一步行血管造影检查，这样患者受到两次放射线照射。因此，这是一种两难状态，CCTA主要起到排除诊断的作用，但检查之前你并不知情。

　　血运重建vs. 优化药物治疗

　　新版指南对稳定性冠心病治疗如何选择血运重建或优化药物治疗作了尽可能明确的阐述。医生应综合患者症状、缺血程度和冠状动脉解剖状况，作出正确决策。在临床实践中，应遵循指南。这一领域仍在不断前进之中，FREEDOM试验、SYNTAX试验5年结果给予我们更清晰的路径，指导我们如何临床决策。明年我们将会发布一份有关血运重建的指南。