Myocardial Perfusion Analysis Research Articles

High reproducibility of adenosine stress cardiac MR myocardial perfusion imaging in patients with non-ischaemic dilated cardiomyopathy

ObjectiveTo evaluate the reproducibility of first-pass contrast-enhanced cardiac MR (CMR) myocardial perfusion imaging in patients with non-ischaemic dilated cardiomyopathy (NIDCM).DesignProspective observational study.SettingSingle centre, tertiary care hospital.Participants6 outpatient participants with NIDCM.OutcomeReproducibility...

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Summary A 52-year-old man presented after one episode of effort angina, normal treadmill electrocardiogram (ECG), and clearly positive adenosine cardiac magnetic resonance (aCMR) for reversible perfusion defects in the left anterior descending (LAD) coronary artery territory. Contrast high-dose dipyridamole (0.84 mg/kg per 6 min) stress echocardiography (cSE) demonstrated normal myocardial perfusion (MP) and wall motion at rest, while perfusion defects were shown in the lateral and apical segments after dipyridamole. Wall motion at stress was completely normal and stress/rest Doppler diastolic velocity ratio on the LAD demonstrated reduced flow reserve. In this case, cSE was the provocative test detecting both the LAD and circumflex obstructive lesions, thanks to MP analysis, while wall motion assessment was negative, not different from treadmill ECG, and aCMR highlighted only the LAD disease. Learning points In spite of the low sensitivity of wall motion assessment during stress-echocardiography to detect coronary artery disease (CAD) in patients with multivessel disease and balanced ischemia, the addition of cSE with myocardial perfusion assessment, is not only able to overcome this limitation of false negative rate on a per-patient basis, but may also depict multivessel myocardial perfusion defects more efficiently than aCMR, as in the reported case, thanks to high spatial resolution. Myocardial perfusion assessment during cSE, although not always technically feasible, has a very high spatial and temporal resolution which can easily demonstrate multivessel subendocardial perfusion defects during maximal vasodilation, which is often the only detectable marker of multivessel, balanced CAD. It is known that wall motion analysis during pharmacologic stress may result in falsely negative multivessel disease; in these cases perfusion imaging or Doppler measurement of coronary flow reserve may be helpful to detect multivessel obstructive CAD, which is a significant and dismal prognostic finding. aCMR is assumed as the perfect imaging modality for CAD detection, but in selected cases, such as the one presented, an advanced echocardiographic method in experienced hands can provide even more comprehensive results.

Incremental Value of Pharmacological Stress Cardiac Dual-Energy CT Over Coronary CT Angiography Alone for the Assessment of Coronary Artery Disease in a High-Risk Population

The purpose of this article is to prospectively determine the value of stress dual-energy CT (DECT) myocardial perfusion imaging to coronary CT angiography (CTA) for the assessment of coronary artery disease (CAD) in a high-risk population. We prospectively enrolled 29 consecutive patients who were referred for cardiac SPECT examinations for known or suspected CAD to also undergo pharmacologic stress cardiac DECT. In 25 patients, cardiac catheterization was available as the reference standard for morphologically significant stenosis. The performance of coronary CTA alone, DECT myocardial perfusion alone, and the combination of both was assessed by calculating sensitivity, specificity, and AUC values. For morphologically significant stenosis, coronary CTA alone and myocardial DECT assessment alone had 95% sensitivity and 50% specificity. The combined approach yielded 100% sensitivity and 33% specificity if either was positive and 90% sensitivity and 67% specificity if both were positive. The AUC value was highest (0.78) if both were positive. For hemodynamically significant lesions, coronary CTA alone had 91% sensitivity and 38% specificity, and DECT alone had 95% sensitivity and 75% specificity. The combined approach yielded 100% sensitivity and 38% specificity if either was positive and 86% sensitivity and 75% specificity if both were positive. AUC values were highest for DECT alone (0.85) and the "both positive" evaluation (0.80). The combined analysis of coronary CTA and DECT myocardial perfusion reduces the number of false-positives in a high-risk population for CAD and outperforms the purely anatomic test of coronary CTA alone for the detection of morphologically and hemodynamically significant CAD.

Influence of spatial resolution on the accuracy of quantitative myocardial perfusion in first pass stress perfusion CMR.

PurposeHigh-resolution myocardial perfusion analysis allows for preserving spatial information with excellent sensitivity for subendocardial ischemia detection. However, it suffers from low signal-to-noise ratio. Commonly, spatial averaging is used to increase signal-to-noise ratio. This bears the risk of losing information about the extent, localization and transmurality of ischemia. This study investigates spatial-averaging effects on perfusion-estimates accuracy.MethodsPerfusion data were obtained from patients and healthy volunteers. Spatial averaging was performed on voxel-based data in transmural and angular direction to reduce resolution to 50, 20, and 10% of its original value. Fit quality assessment method is used to measure the fraction of modeled information and remaining unmodeled information in the residuals.ResultsFraction of modeled information decreased in patients as resolution reduced. This decrease was more evident for Fermi and exponential in transmural direction. Fermi and exponential showed significant difference at 50% resolution (Fermi P < 0.001, exponential P =0.0014). No significant differences were observed for autoregressive-moving-average model (P = 0.081). At full resolution, autoregressive-moving-average model has the lowest fraction of residual information (0.3). Differences were observed comparing ischemic regions perfusion-estimates coefficient of variation at transmural and angular direction.ConclusionAngular averaging preserves more information compared to transmural averaging. Reducing resolution level below 50% at transmural and 20% at angular direction results in losing information about transmural perfusion differences. Maximum voxel size of 2 × 2 mm2 is necessary to avoid loss of physiological information due to spatial averaging. Magn Reson Med 73:1623–1631, 2015. © 2014 The Authors. Magnetic Resonance in Medicine Published by Wiley Periodicals, Inc. on behalf of International Society of Medicine in Resonance.

Quantitative pixelwise myocardial perfusion maps from first-pass perfusion MRI.

To calculate and evaluate absolute quantitative myocardial perfusion maps from rest first-pass perfusion MRI. 10 patients after revascularization of myocardial infarction underwent cardiac rest first-pass perfusion MRI. Additionally, perfusion examinations were performed in 12 healthy volunteers. Quantitative myocardial perfusion maps were calculated by using a deconvolution technique, and results were compared were the findings of a sector-based quantification. Maps were typically calculated within 3 min per slice. For the volunteers, myocardial blood flow values of the maps were 0.51 ± 0.16 ml g(-1) per minute, whereas sector-based evaluation delivered 0.52 ± 0.15 ml g(-1) per minute. A t-test revealed no statistical difference between the two sets of values. For the patients, all perfusion defects visually detected in the dynamic perfusion series could be correctly reproduced in the maps. Calculation of quantitative perfusion maps from myocardial perfusion MRI examinations is feasible. The absolute quantitative maps provide additional information on the transmurality of perfusion defects compared with the visual evaluation of the perfusion series and offer a convenient way to present perfusion MRI findings. Voxelwise analysis of myocardial perfusion helps clinicians to assess the degree of tissue damage, and the resulting maps are a good tool to present findings to patients.

Analysis of myocardial perfusion from vasodilator stress computed tomography: Does improvement in image quality by iterative reconstruction lead to improved diagnostic accuracy?

BackgroundIterative reconstruction (IR) in cardiac CT has been shown to improve confidence of interpretation of noninvasive coronary CT angiography (CTA). ObjectiveWe hypothesized that IR would also improve the quality of vasodilator stress coronary CT images acquired with low tube voltage to assess myocardial perfusion and the accuracy of the detection of perfusion abnormalities by using quantitative 3-dimensional (3D) analysis. MethodsWe studied 39 consecutive patients referred for coronary CTA (256-slice scanner; Philips), who underwent additional imaging (100 kV, prospective gating) with regadenoson (0.4 mg; Astellas). Stress images were reconstructed with different algorithms: filtered back projection (FBP) and IR (iDose; Philips). Image quality was quantified by signal-to-noise and contrast-to-noise ratios in the blood pool and the myocardium. Then, FBP and separately IR images were analyzed with custom 3D analysis software to quantitatively detect perfusion defects. Accuracy of detection was compared with perfusion abnormalities predicted by coronary stenosis >50% on coronary CTA. ResultsFive patients with image artifacts were excluded. In the remaining 34 patients, both signal-to-noise and contrast-to-noise ratios increased with IR, indicating improvement in image quality compared with FBP. For 3D perfusion analysis, 10 patients with normal coronary arteries were used as a reference to correct for x-ray attenuation variations in normal myocardium. In the remaining 24 patients, reduced noise levels in the IR images compared with FBP resulted in tighter attenuation distribution and improved detection of perfusion abnormalities. ConclusionIR significantly improves image quality on regadenoson stress CT images acquired with low tube voltage, leading to improved 3D quantitative evaluation of myocardial perfusion.

Diaphragm border detection in coronary X-ray angiographies: New method and applications

X-ray angiography is widely used in cardiac disease diagnosis during or prior to intravascular interventions. The diaphragm motion and the heart beating induce gray-level changes, which are one of the main obstacles in quantitative analysis of myocardial perfusion. In this paper we focus on detecting the diaphragm border in both single images or whole X-ray angiography sequences. We show that the proposed method outperforms state of the art approaches. We extend a previous publicly available data set, adding new ground truth data. We also compose another set of more challenging images, thus having two separate data sets of increasing difficulty. Finally, we show three applications of our method: (1) a strategy to reduce false positives in vessel enhanced images; (2) a digital diaphragm removal algorithm; (3) an improvement in Myocardial Blush Grade semi-automatic estimation.

MR myocardial perfusion analysis of first-pass enhancement kinetics with a lagrangian approach

Background Observation of the kinetics of tissue enhancement after the injection of a bolus of tracer has been used for the analysis of perfusion and related variables. In general, a gradient of concentration in the exchanging vascular compartment between the ar terial and venous ends is represented in models via focus on maintaining the detailed balance between the advective and diffusive exchange processes. Conventionally, this is by considering the exchange in an Eulerian framework, based on considering the exchange within each compartment as a separate unit (e.g., tissue homogeneity (TH) model [1]). Herein, we present a Lagrangian approach to the exchange modeling, such that the blood flowing between compartments is considered as the primary unit, and, thereby, allowing for coarser discretization and more efficient calculations (Figure 1a). Methods

Myocardial Blood Flow Quantification from MRI – an Image Analysis Perspective

First-pass perfusion imaging allows for a very high spatial resolution, noninvasive and radiation free quantification of myocardial blood flow. True quantification of perfusion images offers a unique capability to localize and measure subendocardial ischemia. Several techniques such as semiquantitative, model independent and model dependent methods are available for calculating MBF from perfusion CMR. However, for accurate perfusion quantification a few requirements need to be addressed beforehand. These include but are not limited to the relationship between the amount of injected contrast agent and the signal intensity of the MR image, used pulse sequence, and the extraction of an arterial input function. Moreover, with the new advances in CMR perfusion imaging, high spatial resolution voxel-wise quantitative analysis of myocardial perfusion is feasible. Voxel-wise quantification has the potential to combine the advantage of visual analysis with the objective and reproducible evaluation made by true quantitative methods.

Dose response of the intravascular contrast agent gadofosveset trisodium in MR perfusion imaging of the myocardium using semiquantitative evaluation

To evaluate appropriate injection protocols for gadofosveset at 1.5 and 3 T magnetic resonance imaging (MRI) for semiquantitative myocardial perfusion analysis. Eighteen young healthy volunteers were subjected to first-pass perfusion cardiac scans at 1.5 and 3 T MRI using three different injection protocols for gadofosveset (0.00375, 0.0075, and 0.0150 mmol/kg bodyweight) and two perfusions. At both field strengths a T1-weighted saturation recovery turboFLASH sequence with parallel imaging was employed. Peak signal-to-noise ratio (SNR), maximum contrast enhancement ratio (CER), peak-baseline difference, and upslope values were assessed. Moreover, sectors with dark banding artifacts were evaluated. Significant differences of the upslope values for first compared to second perfusion could be observed for the medium- and high-dose groups at 1.5 T (P < 0.01), but not at 3 T. Sectors with dark banding artifacts during first perfusion occurred significantly more often at the highest dose of gadofosveset compared to the lowest dose at 1.5 T (P = 0.04) and 3 T (P < 0.01). The best injection protocol for semiquantitative perfusion analysis at 1.5 T is 0.00375 mmol/kg, as higher doses lead to lower upslope values during the second perfusion. At 3 T 0.0075 mmol/kg should be used to avoid dark banding artifacts.

Dekstrokardide Miyokard Perfüzyon Spect Görüntüleme: Olgu Sunumu

The myocardial perfusion scintigraphy acquisition and analysis present some technical differences in the rare dextrocardia cases. Here we report a case of a 38 year-old woman with dextrocardia who had been applied myocardial perfusion scintigraphy. Presented case showed that the thoracic and abdominal organs had a mirror image with situs inversus totalis type dextrocardia. The incidence of coronary heart disease and life span of people with situs inversus totalis are the same as the normal population. So we may apply myocardial perfusion scintigraphy to this patient group. The current case is presented in order to remind the special applications of myocardial perfusion SPECT imaging in patients with dextrocardia. Conflict of interest:None declared.

Is it possible to do without the study of myocardial perfusion in 2013?

The analysis of myocardial perfusion is a key step in the cardiac MRI examination. In routine work, this exploration carried out at rest is based on the qualitative first pass study of gadolinium with an ECG-triggered saturation recovery bFFE sequence. In view of recent knowledge, the analysis of the myocardial perfusion under vasodilator stress may be carried out by scintigraphy or MRI, the latter benefiting from the absence of exposure to ionizing rays and a lower cost. Besides coronary disease, the perfusion sequence provides a rich semiology to compare with the clinics and the data from other sequences. Arterial Spin Labeling (ASL) is an alternative technique used in the animal to quantify myocardial perfusion.

Dose response of the intravascular contrast agent gadofosveset trisodium in MR perfusion imaging of the myocardium using a quantitative evaluation

This study was performed to determine the best concentration of gadofosveset at 1.5 and 3 T MRI for quantitative myocardial perfusion analysis. 18 healthy volunteers have been examined at a 1.5 and a 3 T MRI system assigned to one of three dose groups: low dose (0.00375 mmol/kg), medium dose (0.0075 mmol/kg), high dose (0.0150 mmol/kg). A T1-weighted saturation recovery turboFLASH sequence with parallel imaging was used. Two perfusion scans were performed for each field strength and volunteer. Peak signal-to-noise-ratio, maximum contrast-enhancement-ratio and myocardial blood flow (MBF) were calculated. MBF values were significantly higher at 1.5 T in the medium and the high dose groups than in the low dose group (p < 0.001). Higher MBF values could be found at 3 T for the second perfusion scan in the medium and both perfusion scans in the high dose group compared to the low dose group. Optimal dose of gadofosveset for quantitative perfusion analysis at 1.5 T is 0.00375 mmol/kg as higher doses caused overestimation of the MBF. At 3 T 0.0075 mmol/kg seems to be the best dose for a single perfusion scan, while for a second perfusion scan MBF may be overestimated.

The relationship between spatial resolution levels and quantitative myocardial perfusion

Background Dynamic contrast enhanced cardiovascular magnetic resonance imaging (DCE-CMR) allows for high-resolution analysis of myocardial perfusion by preserving important spatial information. However high resolution perfusion quantification suffers from the poor signal-to-noise ratio (SNR) of voxel-based data. Previously spatial averaging (segmental or sub-segmental analysis) has been used to improve the SNR. This approach results in reduction of spatial resolution and potentially in a loss of information about the extent, localization and transmurality of

3 Tesla is the preferred field strength for perfusion imaging in coronary artery disease – a comparison to 1.5 Tesla and fractional flow reserve

Background Adenosine perfusion imaging at 1.5 Tesla (T) has been shown to yield good diagnostic values in comparison to quantitative coronary angiography. Perfusion imaging at 3 T has the potential benefit of higher contrast- and signalto-noise ratios. However, little is known about diagnostic performance of 3 T perfusion imaging in comparison to 1.5 T and in comparison to invasive measurement of fractional flow reserve (FFR). We sought to evaluate visual and quantitative assessment of adenosine perfusion at 3 T in comparison to 1.5 T and to coronary angiography in patients presenting with suspected coronary artery disease (CAD). Methods 86 consecutive patients with suspected CAD were enrolled in this study. All patients underwent adenosine perfusion at 3 T (Achieva, Philips Medical Systems) and 1.5 T (Intera, Philips Medical Systems) within 72 hours with subsequent coronary angiography within 72 hours. Two independent patient groups were formed. In group 1 1 (N=52) quantitative coronary analysis (QCA) was compared to qualitative perfusion MRI imaging. Group 2 (N=34) underwent FFR measurement in all three major coronary arteries in comparison to quantitative myocardial perfusion reserve (MPR). Results In both groups a significant (p<0.05) higher sensitivity and specificity (group 1: 0.88 vs 0.80 and 0.96 vs. 0.89, p<0.01; group 2 0.91 vs. 0.62 and 1.0 vs. 0.77, p<0.001) was found for 3 T when compared to 1.5 T. Conclusions 3 T appears to be the superior field strength for visual or quantitative analysis of myocardial perfusion in CAD as shown in our two consecutive patient groups.

Time Efficiency and Diagnostic Accuracy of New Automated Myocardial Perfusion Analysis Software in 320-Row CT Cardiac Imaging

ObjectiveWe aimed to evaluate the time efficiency and diagnostic accuracy of automated myocardial computed tomography perfusion (CTP) image analysis software.Materials and Methods320-row CTP was performed in 30 patients, and analyses were conducted independently by three different blinded readers by the use of two recent software releases (version 4.6 and novel version 4.71GR001, Toshiba, Tokyo, Japan). Analysis times were compared, and automated epi- and endocardial contour detection was subjectively rated in five categories (excellent, good, fair, poor and very poor). As semi-quantitative perfusion parameters, myocardial attenuation and transmural perfusion ratio (TPR) were calculated for each myocardial segment and agreement was tested by using the intraclass correlation coefficient (ICC). Conventional coronary angiography served as reference standard.ResultsThe analysis time was significantly reduced with the novel automated software version as compared with the former release (Reader 1: 43:08 ± 11:39 min vs. 09:47 ± 04:51 min, Reader 2: 42:07 ± 06:44 min vs. 09:42 ± 02:50 min and Reader 3: 21:38 ± 3:44 min vs. 07:34 ± 02:12 min; p < 0.001 for all). Epi- and endocardial contour detection for the novel software was rated to be significantly better (p < 0.001) than with the former software. ICCs demonstrated strong agreement (≥ 0.75) for myocardial attenuation in 93% and for TPR in 82%. Diagnostic accuracy for the two software versions was not significantly different (p = 0.169) as compared with conventional coronary angiography.ConclusionThe novel automated CTP analysis software offers enhanced time efficiency with an improvement by a factor of about four, while maintaining diagnostic accuracy.

Quantitative Myocardial Contrast Supine Bicycle Stress Echocardiography for Detection of Coronary Artery Disease

If compared with two-dimensional echocardiography (2DE), quantitative myocardial contrast echocardiography (MCE) improves detection of coronary artery disease (CAD) during pharmacological stress, but there is paucity of data regarding quantitative MCE performed during supine bicycle stress. To determine the feasibility and accuracy of quantitative MCE and assess its incremental benefit over 2DE for detection of CAD during supine bicycle stress. Sixty-one consecutive patients (47 males, 14 females, mean age 57 ± 12 years) with suspected CAD, who were scheduled for coronary angiography, underwent 2DE and MCE supine bicycle stress. The diagnosis of obstructive CAD (≥50% stenosis) was based on inducible wall-motion and myocardial perfusion abnormalities. For quantitative myocardial perfusion analysis, A, β, and Aβ reserve were derived from myocardial contrast replenishment curves. Quantitative coronary angiography revealed ≥50% stenosis in 41, ≥70% stenosis in 18, single vessel disease in 24, and multivessel disease in 17 patients. If compared with 2DE, quantitative MCE was more sensitive (71% vs. 93%; P < 0.05) and more accurate (74% vs. 89%; P < 0.05) to detect obstructive CAD. The sensitivity of 2DE and quantitative MCE was 61% and 91% (P < 0.05) in 50-69% stenosis, and 63% and 92% (P < 0.05) in single vessel disease. No difference in sensitivity between 2DE and quantitative MCE was found in subjects with ≥70% stenosis (83% vs. 94%, P = NS) and multivessel disease (82% vs. 94%, P = NS). Quantitative MCE enhances sensitivity and accuracy of supine bicycle stress 2DE for detection of obstructive CAD, and this incremental benefit is especially present in less severe disease.

Comparative Prediction of Cardiac Events by Wall Motion, Wall Motion Plus Coronary Flow Reserve, or Myocardial Perfusion Analysis: A Multicenter Study of Contrast Stress Echocardiography

This study sought to determine whether the increasing difficulty of assessing wall motion (WM), Doppler coronary flow reserve on the left anterior descending coronary artery (CFR-LAD), and myocardial perfusion (MP) during stress echocardiography (SE) was justified by increasing prognostic information in patients with known or suspected coronary artery disease. The use of echocardiographic contrast agents during SE permits the assessment of both CFR-LAD and MP, but their relative incremental prognostic value is undefined. This study followed a multicenter cohort of 718 patients for 16 months after high-dose dipyridamole contrast SE for evaluation of known or suspected coronary artery disease. The ability of WM, CFR-LAD, and MP to predict cardiac events was studied by multivariable models and risk reclassification. Abnormal SE was detected as a reversible WM abnormality in 18%, reversible MP defect in 27%, and CFR-LAD <2 in 38% of subjects. Fifty cardiac events occurred (annualized event rate 6.0%). A normal MP stress test had a 1-year hard event rate of 1.2%. The C-index of outcomes prediction based on clinical data was improved with MP (p < 0.001) and WM/CFR-LAD (p = 0.037), and MP (p = 0.003) added to clinical and WM data. Net risk reclassification was improved by adding MP (p < 0.001) or CFR-LAD (net reclassification improvement p = 0.001) in addition to clinical and WM data. The model including clinical data, WM/CFR-LAD, and MP performed better than that without MP did (p = 0.012). The multiparametric assessment of WM, CFR-LAD and MP during stress testing in patients with known or suspected coronary artery disease is feasible. Contrast SE allowed better prognostication, irrespective of the use of CFR-LAD or MP. The addition of either CFR-LAD or MP assessment to standard WM analysis and clinical parameters yielded progressively higher values for the prediction of cardiac events and may be required in today's intensively treated patients undergoing SE, because their average low risk of future cardiac events requires methods with higher predictive sensitivity than that available with standalone WM assessment.

Evaluation of chronic ischemic heart disease with myocardial perfusion and regional contraction analysis by contrast-enhanced 256-MSCT

To investigate myocardial viability in chronic ischemic heart disease by myocardial perfusion and regional contraction analysis using 256-slice MSCT coronary angiography (CCTA). In 30 patients with prior myocardial infarction (MI), CCTA with retrospective ECG-gating and stress-redistribution thallium-201 SPECT were performed. Using the same raw data as used for CCTA, myocardial perfusion imaging (CT-MPI) was reconstructed at four phases during the cardiac cycle. Mean myocardial attenuation and wall thickness at end-systole and end-diastole were measured in the MI areas depicted by SPECT, and they were compared between viable and non-viable segments categorized by SPECT. End-systolic thickness was significantly greater for viable than for non-viable segments (12.0 ± 3.2 vs. 9.6 ± 3.5 mm, p = 0.0017). There was no difference in end-diastolic thickness. Myocardial attenuation was significantly higher for viable than for non-viable segments in the subendocardium (62 ± 13 vs. 70 ± 11 HU, p = 0.003) and the epicardium (65 ± 13 vs. 80 ± 15 HU, p = 0.0002). The systolic wall thinning and epicardial low-attenuation areas were the indicative findings of CT-MPI for non-viable segments in the prior MI.

Incremental Value of Perfusion over Wall‐Motion Abnormalities with the Use of Dobutamine–Atropine Stress Myocardial Contrast Echocardiography and Magnetic Resonance Imaging for Detecting Coronary Artery Disease

Recently, multimodality imaging has been demonstrated to improve the sensitivity of dobutamine stress for the diagnosis of coronary artery disease (CAD). We sought to determine the additional value of myocardial perfusion (MP) over wall-motion (WM) analysis for detecting CAD, using real time myocardial contrast echocardiography (RTMCE) and cardiovascular magnetic resonance (CMR), in the same group of patients. We studied 42 patients who underwent RTMCE and CMR during high-dose dobutamine stress with early injection of atropine. No difference was observed in the diagnostic accuracy of RTMCE and CMR for detecting angiographically significant CAD when considering WM analysis alone (73% [95% CI, 65-81] and 78% [95% CI, 70-84], respectively; P = NS) or combined analysis of WM and MP (80% [95% CI, 73-97] and 83% [95% CI, 77-90], respectively; P = NS). Combined analysis of WM and MP had higher sensitivity than the analysis of WM alone by RTMCE (88% [95% CI, 75-100] vs. 72% [95% CI, 54-90]) and by CMR (92% [95% CI, 81-100] vs. 80% [95% CI, 64-96]) with no differences in specificity. The association of abnormal WM and MP abnormalities during high-dose dobutamine-atropine stress had additional value for detecting CAD over the analysis of WM alone, both by RTMCE (χ(2) = 16.16-24.13; P = 0.005) and CMR (χ(2) = 12.73-27.41; P = 0.001). RTMCE and CMR using the same dobutamine-atropine stress protocol had comparable diagnostic accuracies for the detection of angiographically significant CAD. MP imaging had additional value over WM analysis for the diagnosis of CAD, both at RTMCE and CMR.