Utility of adenosine stress perfusion CMR to assess paediatric coronary artery disease

Abstract Background Invasive coronary angiography (ICA) is still the reference test in suspected non-ST elevation myocardial infarction (NSTEMI), although a substantial number of patients do not have obstructive coronary artery disease (CAD). Early cardiovascular magnetic resonance (CMR) may be a useful gatekeeper for ICA in this setting. The main objective was to investigate the accuracy of CMR to detect obstructive CAD in NSTEMI. Methods This study is a sub-analysis of a randomized controlled trial investigating whether a non-invasive imaging-first strategy safely reduced the number of ICA compared to routine clinical care in suspected NSTEMI (acute chest pain, non-diagnostic electrocardiogram, high sensitivity troponin T > 14 ng/L), and included 51 patients who underwent CMR prior to ICA. A stepwise approach was used to assess the diagnostic accuracy of CMR to detect (1) obstructive CAD (diameter stenosis ≥ 70% by ICA) and (2) an adjudicated final diagnosis of acute coronary syndrome (ACS). First, in all patients the combination of cine, T2-weighted and late gadolinium enhancement (LGE) imaging was evaluated for the presence of abnormalities consistent with a coronary etiology in any sequence. Hereafter and only when the scan was normal or equivocal, adenosine stress-perfusion CMR was added. Results Of 51 patients included (63 ± 10 years, 51% male), 34 (67%) had obstructive CAD by ICA. The sensitivity, specificity and overall accuracy of the first step to diagnose obstructive CAD were 79%, 71% and 77%, respectively. Additional vasodilator stress-perfusion CMR was performed in 19 patients and combined with step one resulted in an overall sensitivity of 97%, specificity of 65% and accuracy of 86%. Of the remaining 17 patients with non-obstructive CAD, 4 (24%) had evidence for a myocardial infarction on LGE, explaining the modest specificity. The sensitivity, specificity and overall accuracy to diagnose ACS (n = 43) were 88%, 88% and 88%, respectively. Conclusion CMR accurately detects obstructive CAD and ACS in suspected NSTEMI. Non-obstructive CAD is common with CMR still identifying an infarction in almost one-quarter of patients. CMR should be considered as an early diagnostic approach in suspected NSTEMI. Trial registration. The CARMENTA trial has been registered at ClinicalTrials.gov with identifier NCT01559467.

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Abstract 4174: Adenosine-Stress CT Myocardial Perfusion Imaging: Comparison with Stress Myocardial Perfusion MRI in Patients with Coronary Artery Disease

Circulation ◽

10.1161/circ.118.suppl_18.s_836-a ◽

2008 ◽

Vol 118 (suppl_18) ◽

Author(s):

Masaki Ishida ◽

Hajime Sakuma ◽

Shingo Kato ◽

Motonori Nagata ◽

Nanaka Ishida ◽

...

Keyword(s):

Coronary Artery Disease ◽

Coronary Artery ◽

Myocardial Perfusion ◽

Myocardial Ischemia ◽

Perfusion Ct ◽

Perfusion Mri ◽

Adenosine Stress ◽

Stress Perfusion ◽

Stress Myocardial Perfusion ◽

Artery Disease

Background: CT coronary angiography with vasodilator stress might be of great value in detecting both myocardial ischemia and morphological stenoses of the coronary arteries. Stress myocardial perfusion MRI has been shown to provide accurate assessment of presence and extent of myocardial ischemia in patients with coronary artery disease(CAD). The aim of this study was to determine the value of stress myocardial perfusion CT for the detection of myocardial ischemia by using stress perfusion MRI as a reference method. Methods: The study protocol was approved by the institutional review board and all participants gave written informed consent. Cardiac CT was performed in 12 patients with suspected CAD by using a 64-detector MDCT scanner. Beta-blocker was orally administered prior to CT study. During continuous injection of adenosine, contrast enhanced CT images of the heart were acquired with retrospectively gated helical CT protocol. Adenosine stress myocardial perfusion MRI was performed within 2 weeks from CT perfusion study in all patients. Stress myocardial perfusion MDCT and MR images were qualitatively assessed by two observers using a 16-segment model. Results: All patients completed stress CT study protocol without significant side-effect. Averaged heart rate was 62+/−10 beats/min in the baseline state and 74+/−14 beats/min during adenosine stress. Perfusion abnormality during stress was observed in 83 (43.2%) of 192 segments by MDCT and in 89 (46.4%) of 192 segments by MRI. On a vessel based analysis, stress CT and stress MRI findings are concordant in 30 (83.3%) of 36 territories. The sensitivity, specificity and accuracy of adenosine stress myocardial perfusion CT for the predicting abnormal perfusion on stress perfusion MRI was 84.6%, 80% and 83.3%, respectively. Conclusion: Adenosine stress myocardial perfusion CT can be successfully performed in patients with CAD. Excellent agreement between stress myocardial perfusion CT and MRI observed in this study indicates the value of stress CT approach for comprehensive assessment of morphology and functional significance of CAD.

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Comparison of exercise electrocardiography and stress perfusion CMR for the detection of coronary artery disease in women

Journal of Cardiovascular Magnetic Resonance ◽

10.1186/1532-429x-14-36 ◽

2012 ◽

Vol 14 (1) ◽

Cited By ~ 8

Author(s):

Simon Greulich ◽

Oliver Bruder ◽

Michele Parker ◽

Julia Schumm ◽

Stefan Grün ◽

...

Keyword(s):

Coronary Artery Disease ◽

Coronary Artery ◽

Stress Perfusion ◽

Exercise Electrocardiography ◽

Artery Disease ◽

Perfusion Cmr

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Abstract 4718: Combined Adenosine Stress Perfusion and Coronary Angiography Using 320-Row Detector Dynamic Volume Computed Tomography in Patients with Suspected Coronary Artery Disease

Circulation ◽

10.1161/circ.118.suppl_18.s_936-a ◽

2008 ◽

Vol 118 (suppl_18) ◽

Author(s):

Richard T George ◽

Kakuya Kitagawa ◽

Katherine Laws ◽

Albert C Lardo ◽

Joao A Lima

Keyword(s):

Computed Tomography ◽

Coronary Artery Disease ◽

Coronary Artery ◽

Gold Standard ◽

Adenosine Stress ◽

Stress Perfusion ◽

Slice Thickness ◽

Effective Radiation Dose ◽

Artery Disease ◽

Sensitivity Specificity

Dynamic volume 320-row detector computed tomography (CT), with full cardiac coverage, allows for the combination of non-invasive angiography (CTA) performed at rest with myocardial perfusion imaging (MPI) during adenosine stress. The purpose of this study was to test the accuracy of combined CTA and MPI using dynamic volume 320-row detector CT to identify atherosclerosis causing territorial ischemia. Eighteen patients with chest pain and intermediate to high pre-test likelihood of coronary artery disease (CAD) underwent rest CTA and stress CT-MPI following radionuclide MPI using the following prospective ECG-gated protocol: Rest CTA: 320 × 0.5mm, 120 kV, 400 mA, 70 – 80% R-R interval followed by Stress CT-MPI: adenosine (140μg/kg/min), 320 × 0.5mm, 120 kV, 400 mA, 70 – 80% R-R interval. CT-MPI images were reconstructed in the short axis with a 3 mm slice thickness. The transmural perfusion ratio (TPR) was calculated by dividing the endocardial attenuation density (AD) by the epicardial AD in each sector. Ischemia was defined as a TPR <0.99 on adenosine stress CT-MPI that normalized on the rest CTA images. CTA was analyzed for stenoses ≥50% and radionuclide MPI was analyzed for fixed and reversible perfusion abnormalities. Using a 17-segment model in a territory/vessel based analysis, the combination of CTA + CT-MPI was compared with CTA 3 radionuclide MPI (gold standard) for its ability to detect atherosclerosis causing territorial ischemia. Mean TPRs in ischemic and normal territories were 0.90±0.09 and 1.13±0.10, respectively (p<0.001). The sensitivity, specificity, positive (PPV) and negative predictive value (NPV) for CTA + CT-MPI were 86%, 85%, 67, and 94% compared with the gold standard; respectively. However, when adjusting for balanced multivessel disease the sensitivity, specificity, PPV, and NPV were 89%, 94%, 89%, and 94%; respectively. Mean effective radiation dose for the combined rest (4.9±0 mSv) and stress (8.5±0.5mSv) protocols was 13.4±0.5 mSv. The combination of CTA and CT -MPI, using 320-row detector dynamic volume CT, is capable of accurately identifying myocardial ischemia in the presence of obstructive atherosclerosis and compares well with CTA/radionuclide MPI.

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