第一部分

疑诊冠心病人群冠状动脉CT血管成像适用性研究：

基于年龄、性别和症状的验前概率模型

目的：2019年欧洲心脏病学会（European Society of Cardiology, ESC）指南提出更新的验前概率（pre-test probability, PTP）模型用于评估冠心病（coronary artery disease, CAD）发生风险，但其在中国人群中的预测效能尚未得到验证。本研究旨在通过冠状动脉CT血管成像（coronary computed tomography angiography, CCTA）结果评估2019 ESC-PTP模型在中国疑诊CAD患者人群中的适用性。

方法：连续纳入26 346例疑诊CAD并接受CCTA检查的患者，基于年龄、性别及胸痛症状计算2019 ESC-PTP与2013 ESC-PTP值，将患者分为低危、中危及高危组。通过比较两版模型的阻塞性CAD预估概率及CCTA检出的阻塞性CAD患病率评估更新的2019 ESC-PTP模型的预测效能。

结果：最终纳入分析的11 234例患者中，CCTA检出的阻塞性CAD患者占16.9%（1 896/11 234）。2019 ESC-PTP模型较2013 ESC-PTP模型校准性能更优。风险分层的结果显示，80.9%的患者（男性67.9%，女性94.4%）与2019 ESC-PTP模型风险分类一致，但该模型低估了年轻患者（检出患病率7.5% vs. 预估概率2.5%，P<0.001）及非心绞痛性胸痛患者（检出患病率13.7% vs. 预估概率8.2%，P<0.001）的阻塞性CAD风险。

结论：2019 ESC-PTP模型对因疑诊CAD行CCTA检查的中国人群总体具有良好校准性能，但对年轻患者及非心绞痛性胸痛患者人群存在风险低估现象。

第二部分

疑诊冠心病人群冠状动脉粥样硬化情况及他汀类药物

应用现状：一项国内多中心横断面研究

目的：探讨中国疑诊冠心病（coronary artery disease, CAD）人群经冠状动脉CT血管成像（coronary computed tomography angiography, CCTA）检出的冠状动脉粥样硬化患病率以及他汀类药物使用、依从性及血脂达标情况。

方法：纳入25 904例≥30岁接受CCTA检查的中国疑诊CAD人群，患者无已知心血管病病史（包括心梗、脑卒中及冠状动脉血运重建术史）且临床及影像学资料完整。统计CCTA检出的冠状动脉粥样硬化病变（包括非阻塞性CAD及阻塞性CAD）患病率，并按照性别、年龄进行分层。患者的基线他汀类药物用药率及依从性情况根据不同临床特征及冠状动脉粥样硬化负荷分别统计。患者的基线低密度脂蛋白胆固醇（low-density lipoprotein cholesterol, LDL-C）水平根据冠状动脉粥样硬化负荷进行分组统计。

结果：中国疑诊CAD人群冠状动脉粥样硬化患病率为58.1%，阻塞性CAD患病率为17.6%，且无论男性或女性，冠状动脉粥样硬化的患病率及严重程度随年龄增长而提高。CCTA检查前的基线患者他汀类药物使用率为23.9%，高龄、更低的教育程度、有胸痛症状、合并糖尿病、合并高血压及更高的冠状动脉粥样硬化负荷均与更高的他汀类药物使用率有相关性（P均<0.001），用药患者中依从性好的占61.9%。CCTA检出存在冠状动脉粥样硬化的患者中，超过一半的患者LDL-C≥2.6mmol/L，未达到指南推荐的降脂目标。

结论：基于CCTA检查，中国疑诊CAD人群冠状动脉粥样硬化患病率为58.1%，阻塞性CAD患病率为17.6%。该人群他汀类药物的使用率、依从性及血脂达标情况仍不理想，这表明未来需要进一步改进心血管病预防干预的管理策略。

第三部分

比较冠状动脉CT血管成像与临床危险评分在心血管病预防

他汀决策中的作用

目的：本研究旨在比较冠状动脉CT血管成像（coronary computed tomography angiography, CCTA）与指南推荐的临床风险评估对疑诊冠心病（coronary artery disease, CAD）门诊患者他汀类药物分配决策的价值。

方法：纳入7 860例接受CCTA检查的疑诊CAD门诊患者，基于指南推荐的临床风险评估和CCTA结果进行风险分层并进行对比，评估两者对动脉粥样硬化性心血管疾病（atherosclerotic cardiovascular disease, ASCVD）事件及主要不良心脑血管事件（major adverse cardiac and cerebrovascular event, MACCE）的预测能力。针对中危患者，进一步比较CCTA与冠状动脉钙化积分（coronary artery calcium score, CACS）的预测效能。

结果：中位随访3.6年期间，共发生83例（1.1%）ASCVD事件和170例（2.2%）MACCE。事件发生率随他汀治疗推荐强度（如ASCVD事件：不推荐他汀组1.5/1 000人年、中等强度降脂组4.1/1 000人年、强化降脂组8.9/1 000人年）及冠脉狭窄程度（如ASCVD事件：无斑块组0.7/1 000人年、非阻塞性CAD组5.1/1 000人年、阻塞性CAD组11.2/1 000人年）增加而升高。根据CCTA结果的分层分析显示，更高强度的降脂推荐并非ASCVD事件及MACCE的独立危险因素。在中危患者中，CCTA与CACS对ASCVD事件的预测效能无统计学差异（受试者工作特征曲线下面积：0.692 vs. 0.702，P=0.78）。

结论：对于疑诊CAD门诊患者的他汀分配决策，CCTA评估较指南推荐的临床风险分层具有更好的重分类能力。

Part 1 Applicability of coronary CT angiography in Chinese patients with suspected coronary artery disease: a pre-test probability model based on age, sex and symptoms

Objectives: The 2019 European Society of Cardiology (ESC) guidelines proposed a pre-test probability (PTP) model to determine the likelihood of coronary artery disease (CAD). However, the prediction accuracy of this model has not yet been evaluated in Chinese patients. This study aimed to validate the 2019 ESC-PTP model in predicting CAD using coronary computed tomography angiography (CCTA) outcomes in Chinese patients.

Methods: A total of 26 346 consecutive patients with suspected CAD who underwent CCTA were included. The 2019 ESC-PTP model and 2013 ESC-PTP model were calculated for each patient, considering age, sex, and the symptom of chest pain, and the patients were categorized into low-, intermediate-, and high-risk groups. The predictive performance of the 2019 ESC-PTP model was evaluated by comparing it with the 2013 ESC-PTP model and the observed prevalence of obstructive CAD from CCTA.

Results: Among the 11 234 patients analyzed in the study, 1 896 (16.9%) patients were found to have obstructive CAD from CCTA. The 2019 ESC-PTP model had better calibration compared to the 2013 ESC-PTP model. After categorization, 80.9% of patients (67.9% in men and 94.4% in women) were in the same risk category as in the 2019 ESC-PTP model, but the risks of younger patients (7.5% versus 2.5%; P<0.001) and patients with non-anginal chest pain (13.7% versus 8.2%; P<0.001) were underestimated in the 2019 ESC-PTP model.

Conclusion: The 2019 ESC-PTP model demonstrated a good calibration in predicting CAD in Chinese patients who underwent CCTA, but it exhibited an underestimation of CAD probability in younger patients and patients with non-anginal chest pain.

Part 2 Coronary atherosclerosis and statin use in a Chinese population with suspected coronary heart disease: a multicenter cross-sectional study

Objectives: The purpose of this study was to investigate the prevalence of coronary atherosclerosis detected by coronary computed tomography angiography (CCTA), as well as the use of statins, adherence to statins, and lipid compliance in Chinese population with suspected coronary artery disease (CAD).

Methods: A total of 25 904 Chinese patients aged ≥30 years with suspected CAD who underwent CCTA were enrolled, with no known history of cardiovascular disease (including myocardial infarction, stroke, and coronary revascularization) and with complete clinical and imaging data. The prevalence of CCTA-detected coronary atherosclerosis (including non-obstructive CAD and obstructive CAD) was analyzed and stratified by sex and age. Baseline statin use and adherence rates were evaluated across clinical characteristics and coronary atherosclerotic burden. Low-density lipoprotein cholesterol (LDL-C) levels were compared among subgroups stratified by atherosclerotic severity.

Results: The overall prevalence of coronary atherosclerosis in the Chinese population with suspected CAD was 58.1%, the prevalence of obstructive CAD was 17.6%. Both the prevalence and severity of coronary atherosclerosis increased with age in both men and women. Baseline statin use before CCTA was 23.9% overall, with higher rates observed in older individuals, those with lower education levels, chest pain, diabetes, hypertension, or greater atherosclerotic burden (all P<0.001). Among statin users, only 61.9% demonstrated good adherence. Over half of the patients with coronary atherosclerosis had LDL-C≥2.6 mmol/L, failing to meet guideline-recommended lipid targets.

Conclusion: In the Chinese population with suspected CAD, the prevalence of coronary atherosclerosis and obstructive CAD detected by CCTA was 58.1% and 17.6%, respectively. Statin use, adherence, and LDL-C target attainment remained suboptimal in this population, highlighting the need to further improve management strategies for cardiovascular disease prevention in the future.

Part 3 Coronary computed tomography angiography versus clinical risk assessment in statin allocation for cardiovascular disease prevention

Objectives: The purpose of this study was to compare coronary computed tomography angiography (CCTA) and guideline-recommended clinical risk assessment for the value in statin allocation in outpatients with suspected coronary artery disease (CAD).

Methods: For the 7 860 eligible outpatients with suspected CAD who underwent CCTA, we evaluate hard atherosclerotic cardiovascular disease (ASCVD) and major adverse cardiac and cerebrovascular event (MACCE) stratified by guideline-recommended clinical risk assessment, and CCTA. For intermediate risk patients, we also compared the predictive value of CCTA and coronary artery calcium score (CACS).

Results: Over a median follow-up period of 3.6 years, a total of 83 (1.1%) hard ASCVD and 170 (2.2%) MACCE occurred. The event rate increased with both the intensity of statin recommendation (e.g., hard ASCVD: 1.5 per 1 000 person-years [PY] for statin not recommended, 4.1 per 1 000 PY for moderate-intensity statin, and 8.9 per 1 000 PY for high-intensity statin) and the severity of coronary stenosis (e.g., hard ASCVD: 0.7 per 1 000 PY for no plaque, 5.1 per 1 000 PY for non-obstructive CAD, and 11.2 per 1 000 PY for obstructive CAD). When stratified by CCTA, higher intensity statin recommendation was not a statistically significant independent risk factor, both for hard ASCVD and MACCE. For the predictive value of hard ASCVD in intermediate risk patients, there was no statistically significant difference between CCTA and CACS (the area under the receiver operating characteristic curve: 0.692 versus 0.702; P=0.78).

Conclusion: CCTA assessment showed a better reclassification ability for statin allocation compared to guideline-recommended clinical risk assessment in outpatients with suspected CAD.