Abstract
AbstractCombined anatomical and functional evaluation of coronary artery disease (CAD) using computed tomography (CT) has recently emerged as an accurate, robust, and non-invasive tool for the evaluation of ischemic heart disease. Cardiac CT has become a one-stop-shop imaging modality that allows the simultaneous depiction, characterization, and quantification of coronary atherosclerosis and the assessment of myocardial ischemia. Advancements in scanner technology (improvements in spatial and temporal resolution, dual-energy imaging, wide detector panels) and the implementation of iterative reconstruction algorithms enables the detection of myocardial ischemia in both qualitative and quantitative fashion using low-dose scanning protocols. The addition of CT perfusion (CTP) to standard coronary CT angiography is a reliable tool to improve diagnostic accuracy. CTP using static first-pass imaging enables qualitative assessment of the myocardial tissue, whereas dynamic perfusion imaging can also provide quantitative information on myocardial blood flow. Myocardial tissue assessment by CTP holds the potential to refine risk in stable chest pain or microvascular dysfunction. CTP can aid the detection of residual ischemia after coronary intervention. Comprehensive evaluation of CAD using CTP might therefore improve the selection of patients for aggressive secondary prevention therapy or coronary revascularization with high diagnostic certainty. In addition, prognostic information provided by perfusion CT imaging could improve patient outcomes by quantifying the ischemic burden of the left ventricle. The current review focuses on the clinical value of myocardial perfusion imaging by CT, current status of CTP imaging and the use of myocardial CTP in various patient populations for the diagnosis of ischemic heart disease.
Highlights
The evaluation of symptomatic patients suggestive of myocardial ischemia is fundamental challenge in clinical care
In the CORE320 (Combined Non-invasive Coronary Angiography and Myocardial Perfusion Imaging Using 320 Detector Computed Tomography, NCT00934037) multicenter study static stress myocardial CTP and single-photon emission computed tomography (SPECT) perfusion were compared in patients with known significant coronary artery disease (CAD) detected by invasive coronary angiography (ICA) and found higher overall diagnostic performance for static CTP [42]
CTP is a promising tool for the identification of the presence and severity of perfusion abnormalities using either qualitative or quantitative analysis in patients with stable or even acute chest pain
Summary
The evaluation of symptomatic patients suggestive of myocardial ischemia is fundamental challenge in clinical care. Due to its high sensitivity and negative predictive value it is an accurate tool to rule out CAD in patients with low-to intermediate risk of obstructive disease [4, 5], finding the proper test for the assessment of patients with suspected CAD without generating unnecessary downstream testing and to guide patient management is challenging. CTP imaging has the potential to improve diagnosis in patients with higher likelihood of CAD or with microvascular disease and to detect residual ischemia after percutaneous coronary intervention. In the FAME (Fractional Flow Reserve versus Angiography for Multivessel Evaluation, NCT00267774) study combining anatomical and functional evaluation (invasive measurement of lesion specific ischemia) of patients with suspected CAD improved clinical outcome [10]. The ISCHEMIA (International Study of Comparative Health Effectiveness with Medical and Invasive Approaches, NCT01471522) trial further improved our understanding on the management of patients with stable angina and proven ischemia [11]. In the ISCHEMIA trial anatomical severity of CAD increased risk for adverse events, whereas proven ischemia did not
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