正常灌注患者心内膜下心肌血流储备的增量预后价值
该多中心PET注册研究纳入6603例负荷/静息Rb-82 PET灌注正常的患者，以Youden指数确定心内膜下MFR（MFRSE）预测主要不良心血管事件（MACE）的最佳切点为2.1，并按MFRTM≥2.0和MFRSE≥2.1分为一致正常组、不一致组（低MFRSE但MFRTM正常）和MFRTM异常组。中位随访4.9年发生1661例MACE，不一致组MACE风险（HR 1.41；95%CI 1.22-1.64）和全因死亡风险（HR 1.36；95%CI 1.14-1.61）均高于一致正常组，其调整年化MACE发生率5.79%介于一致正常组3.99%和MFRTM异常组8.35%之间。结论提示MFRSE可在跨壁血流储备保留的患者中识别临床有意义的风险异质性。
要点
- 灌注正常且MFRTM≥2.0的患者中，MFRSE<2.1者MACE风险仍升高（HR 1.41）。
- 不一致组调整年化MACE发生率5.79%，介于一致正常组3.99%与MFRTM异常组8.35%之间。
- MFRSE有助于在传统PET指标之外细化风险分层。
核心结论
- 在跨壁心肌血流储备保留的患者中，心内膜下MFR降低可识别MACE和全因死亡风险更高的亚组，提供超越传统PET指标的增量预后信息。
研究设计与样本
- 多中心PET注册研究，纳入负荷/静息Rb-82 PET灌注正常且无CABG、心脏移植或LVEF<40%病史的患者，共6603例（一致正常4103例、不一致885例、MFRTM异常1615例），平均年龄66.3±12.4岁，女性54%。
主要发现
- 中位随访4.9年发生1661例MACE；不一致组较一致正常组MACE风险升高（HR 1.41；95%CI 1.22-1.64），全因死亡风险亦升高（HR 1.36；95%CI 1.14-1.61）。
- 不一致组调整年化MACE发生率为5.79%（95%CI 5.10-6.49），一致正常组为3.99%（95%CI 3.67-4.30；P<0.001），MFRTM异常组为8.35%（95%CI 7.71-9.00；P<0.001）。
- 正常、不一致和异常组的MFRTM中位数分别为2.86、2.15和1.72；不一致组患者更年长，高血压、糖尿病、外周动脉疾病和既往PCI比例更高。
关键数值与推荐
- MFRSE预测MACE的最佳切点为2.1（采用Youden指数确定）；MFRTM正常定义为≥2.0。
- 分组标准：一致正常为MFRTM≥2.0且MFRSE≥2.1；不一致为低MFRSE（<2.1）且MFRTM正常（≥2.0）；异常为MFRTM<2.0。
临床怎么用
- 对于Rb-82 PET灌注正常且MFRTM≥2.0的患者，若MFRSE<2.1，应视为MACE和死亡风险升高的中危亚组，可考虑更密切随访或强化危险因素管理。
以上解读依据论文摘要（全文未开放获取或许可不允许翻译转载）。
原文
BACKGROUND: Although the prognostic utility of positron emission tomography (PET) myocardial flow reserve (MFR) is well established, emerging data suggest that reduced subendocardial flows also predict adverse outcomes. However, the incremental value of subendocardial MFR (MFRSE) beyond transmural MFR (MFRTM) remains unclear. METHODS: We studied patients in a multicenter PET registry with normal perfusion on stress/rest Rb-82 PET, excluding those with a previous history of coronary artery bypass surgery, heart transplantation, or left ventricular ejection fraction <40%. The optimal MFRSE cutoff for predicting major adverse cardiovascular events (MACEs; death, myocardial infarction [MI], revascularization, or heart failure [HF] hospitalization) was determined using Youden's index. Patients were stratified into 3 groups: concordant-normal (MFRTM ≥2.0; MFRSE ≥2.1), discordant (low-MFRSE, normal MFRTM), and abnormal MFRTM. Clinical outcomes were compared by MFR groups. RESULTS: Among 6603 patients (normal N=4103; discordant N=885; abnormal N=1615) the mean age was 66.3±12.4 years, and 54% were women. Compared with the concordant-normal group, patients with discordant low-MFRSE were older and more likely to have hypertension, diabetes, peripheral artery disease, and previous percutaneous coronary intervention. The median MFRTM for normal, discordant, and abnormal groups were 2.86, 2.15, and 1.72, respectively. Over a median follow-up of 4.9 years, 1661 MACE events occurred. Discordant low-MFRSE patients had a higher risk of MACE (hazard ratio [HR], 1.41; 95% CI, 1.22-1.64) and all-cause mortality (HR, 1.36; 95% CI, 1.14-1.61) compared with concordant-normal patients. The discordant group had an intermediate absolute risk of MACE, with an adjusted annualized event rate of 5.79% (95% CI, 5.10-6.49) compared with 3.99% (95% CI, 3.67-4.30; P<0.001) in the concordant-normal group and 8.35% (95% CI, 7.71-9.00; P<0.001) in the abnormal MFRTM group. CONCLUSIONS: Subendocardial MFR reveals clinically meaningful risk heterogeneity among patients with preserved transmural flow reserve, helping refine risk stratification beyond traditional PET metrics.
引用
- Lopez DM, Brown JM, Divakaran S, et al. Incremental Prognostic Value of Subendocardial Myocardial Flow Reserve in Patients With Normal Perfusion. Circulation. 2026. PMID: 42237914. doi:10.1161/CIRCULATIONAHA.125.078816
供执业医师工作参考，不替代临床判断；数值与分级以指南原文为准。