Current Cardiology Reports

, Volume 12, Issue 1, pp 90–97 | Cite as

Combined Anatomic and Perfusion Imaging of the Heart

Article

Abstract

Recent technological advances provided clinicians with multiple options for diagnosing and prognosticating patients with coronary artery disease (CAD). Myocardial perfusion imaging with single photon emission computed tomography and positron emission tomography is a powerful tool for assessing physiologically significant coronary atherosclerosis, but is unable to detect subclinical atherosclerosis. Coronary computed tomographic angiography permits rapid noninvasive assessment of the coronaries and demonstrates an impressive negative predictive value in the clinical literature. Nevertheless, the positive predictive value of computed tomographic angiography for clinically significant CAD is suboptimal. The combination of both of these techniques provides an opportunity to the clinician to assess for subclinical atherosclerosis (with important implications for therapy in low-intermediate risk patients) and functionally significant lesions in patients with extensive CAD. However, the application of this technology has to be implemented on a case-by-case basis to avoid unnecessary radiation exposure and cost.

Keywords

Cardiac PET Cardiac CTA Perfusion imaging Subclinical atherosclerosis 

Clinical Trial Acronyms

ACCURACY

Assessment by Coronary Computed Tomographic Angiography of Individuals Undergoing Invasive Coronary Angiography

CORE 64

Coronary Artery Evaluation Using 64-Row Multidetector Computed Tomography Angiography

NHANES

National Health and Nutrition Surveys

SCCT

Society of Cardiovascular Computed Tomography

Notes

Disclosure

Dr. Marcelo Di Carli has received research grants from GE, Siemens, Bracco, and Astellas. No other potential conflicts of interest relevant to this article were reported.

References

Papers of particular interest, published recently, have been highlighted as: •Of importance ••Of major importance

  1. 1.
    Lloyd-Jones D, Adams R, Carnethon M, et al.: Heart Disease and Stroke Statistics—2009 Update: a report from the American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Circulation 2009, 119:e21–e181.CrossRefPubMedGoogle Scholar
  2. 2.
    Stary HC, Chandler AB, Dinsmore RE, et al.: A definition of advanced types of atherosclerotic lesions and a histological classification of atherosclerosis. A report from the Committee on Vascular Lesions of the Council on Arteriosclerosis, American Heart Association. Circulation 1995, 92:1355–1374.PubMedGoogle Scholar
  3. 3.
    Kockx MM, De Meyer GR, Muhring J, et al.: Apoptosis and related proteins in different stages of human atherosclerotic plaques. Circulation 1998, 97:2307–2315.PubMedGoogle Scholar
  4. 4.
    Klocke FJ, Baird MG, Lorell BH, et al.: ACC/AHA/ASNC guidelines for the clinical use of cardiac radionuclide imaging—executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (ACC/AHA/ASNC Committee to Revise the 1995 Guidelines for the Clinical Use of Cardiac Radionuclide Imaging). J Am Coll Cardiol 2003, 42:1318–1333.CrossRefPubMedGoogle Scholar
  5. 5.
    Uren NG, Crake T, Lefroy DC, et al.: Reduced coronary vasodilator function in infarcted and normal myocardium after myocardial infarction. N Engl J Med 1994, 331:222–227.CrossRefPubMedGoogle Scholar
  6. 6.
    Yoshinaga K, Katoh C, Noriyasu K, et al.: Reduction of coronary flow reserve in areas with and without ischemia on stress perfusion imaging in patients with coronary artery disease: a study using oxygen 15-labeled water PET. J Nucl Cardiol 2003, 10:275–283.CrossRefPubMedGoogle Scholar
  7. 7.
    •• Dorbala S, Vangala D, Sampson U, et al.: Value of vasodilator left ventricular ejection fraction reserve in evaluating the magnitude of myocardium at risk and the extent of angiographic coronary artery disease: a 82Rb PET/CT study. J Nucl Med 2007, 48:349–358. This paper discusses a study of 510 patients with suspected CAD who underwent gated rest and vasodilator stress Rb-82 PET/CT. LVEF reserve was the only predictor of left main/three-vessel disease, with an LVEF reserve of greater than +5% demonstrating a negative predictive value of 975 for excluding left main/three-vessel CAD.PubMedGoogle Scholar
  8. 8.
    Di Carli MF, Dorbala S, Hachamovitch R: Integrated cardiac PET-CT for the diagnosis and management of CAD. J Nucl Cardiol 2006, 13:139–144.CrossRefPubMedGoogle Scholar
  9. 9.
    Lertsburapa K, Ahlberg AW, Bateman TM, et al.: Independent and incremental prognostic value of left ventricular ejection fraction determined by stress gated rubidium 82 PET imaging in patients with known or suspected coronary artery disease. J Nucl Cardiol 2008, 15:745–753.PubMedGoogle Scholar
  10. 10.
    Sampson UK, Dorbala S, Limaye A, et al.: Diagnostic accuracy of rubidium-82 myocardial perfusion imaging with hybrid positron emission tomography/computed tomography in the detection of coronary artery disease. J Am Coll Cardiol 2007, 49:1052–1058. This paper discuses a study of 64 consecutive patients with suspected CAD undergoing rest-stress Rb-82 cardiac PET/CT and coronary angiography within 7 days. The sensitivity for detecting CAD in patients with single and multivessel disease was 92% and 95%, respectively.CrossRefPubMedGoogle Scholar
  11. 11.
    Dorbala S, Hachamovitch R, Curillova Z, et al.: Incremental prognostic value of gated Rb-82 positron emission tomography myocardial perfusion imaging over clinical variables and rest LVEF. JACC Cardiovasc Imaging 2009, 2:846–854. This paper discusses a study examining the incremental value of gated Rb-82 PET MPI over clinical variables for predicting survival and future cardiac events. Rb-82 PET MPI provided significant incremental prognostic value to historical/clinical variables and rest LVEF to predict survival free of cardiac events and all-cause death.CrossRefPubMedGoogle Scholar
  12. 12.
    Anagnostopoulos C, Almonacid A, El Fakhri G, et al.: Quantitative relationship between coronary vasodilator reserve assessed by 82Rb PET imaging and coronary artery stenosis severity. Eur J Nucl Med Mol Imaging 2008, 35:1593–1601.CrossRefPubMedGoogle Scholar
  13. 13.
    Di Carli M, Czernin J, Hoh CK, et al.: Relation among stenosis severity, myocardial blood flow, and flow reserve in patients with coronary artery disease. Circulation 1995, 91:1944–1951.PubMedGoogle Scholar
  14. 14.
    Einstein AJ, Moser KW, Thompson RC, et al.: Radiation dose to patients from cardiac diagnostic imaging. Circulation 2007, 116:1290–1305.CrossRefPubMedGoogle Scholar
  15. 15.
    Schuijf JD, Wijns W, Jukema JW, et al.: Relationship between noninvasive coronary angiography with multi-slice computed tomography and myocardial perfusion imaging. J Am Coll Cardiol 2006, 48:2508–2514.CrossRefPubMedGoogle Scholar
  16. 16.
    •• Di Carli MF, Dorbala S, Curillova Z, et al.: Relationship between CT coronary angiography and stress perfusion imaging in patients with suspected ischemic heart disease assessed by integrated PET-CT imaging. J Nucl Cardiol 2007, 14:799–809. The authors studied 110 consecutive patients with suspected CAD undergoing stress Rb-82 PET MPI and CTA in the same setting. CTA was found to have an excellent negative predictive value for diagnosis of CAD (> 95%), but had poor predictive value for identifying myocardial ischemia. A normal PET was a poor discriminator of patients with subclinical atherosclerosis, suggesting complementary roles for these two modalities.CrossRefPubMedGoogle Scholar
  17. 17.
    Budoff M, Dowe D, Jollis J, et al.: Diagnostic performance of 64–multidetector row coronary computed tomographic angiography for evaluation of coronary artery stenosis in individuals without known coronary artery disease: results from the prospective multicenter ACCURACY (Assessment by Coronary Computed Tomographic Angiography of Individuals Undergoing Invasive Coronary Angiography) trial. J Am Coll Cardiol 2008, 52:1724–1732.CrossRefPubMedGoogle Scholar
  18. 18.
    Meijboom WB, Meijs MFL, Schuijf JD, et al.: Diagnostic accuracy of 64-slice computed tomography coronary angiography: a prospective, multicenter, multivendor study. J Am Coll Cardiol 2008, 52:2135–2144.CrossRefPubMedGoogle Scholar
  19. 19.
    Miller JM, Rochitte CE, Dewey M, et al.: Diagnostic performance of coronary angiography by 64-row CT. N Engl J Med 2008, 359:2324–2336.CrossRefPubMedGoogle Scholar
  20. 20.
    Raff GL, Abidov A, Achenbach S, et al.: SCCT guidelines for the interpretation and reporting of coronary computed tomographic angiography. J Cardiovasc Comput Tomogr 2009, 3:122–136.CrossRefPubMedGoogle Scholar
  21. 21.
    Haramati LB, Levsky JM, Jain VR, et al.: CT angiography for evaluation of coronary artery disease in inner-city outpatients: an initial prospective comparison with stress myocardial perfusion imaging. Int J Cardiovasc Imaging 2009, 25:303–313.CrossRefPubMedGoogle Scholar
  22. 22.
    Schenker MP, Dorbala S, Hong ECT, et al.: Interrelation of coronary calcification, myocardial ischemia, and outcomes in patients with intermediate likelihood of coronary artery disease: a combined positron emission tomography/computed tomography study. Circulation 2008, 117:1693–1700. This paper discusses a study of 695 intermediate-risk patients undergoing combined Rb-82 PET MPI and CAC scoring. There was an increase in event rates (death and myocardial infarction) with increasing CAC scores in patients with and without ischemia on PET MPI.CrossRefPubMedGoogle Scholar
  23. 23.
    Scholte AJ, Schuijf JD, Kharagjitsingh AV, et al.: Different manifestations of coronary artery disease by stress SPECT myocardial perfusion imaging, coronary calcium scoring, and multislice CT coronary angiography in asymptomatic patients with type 2 diabetes mellitus. J Nucl Cardiol 2008, 15:503–509.CrossRefPubMedGoogle Scholar
  24. 24.
    Schepis T, Gaemperli O, Koepfli P, et al.: Added value of coronary artery calcium score as an adjunct to gated SPECT for the evaluation of coronary artery disease in an intermediate-risk population. J Nucl Med 2007, 48:1424–1430.CrossRefPubMedGoogle Scholar
  25. 25.
    Rosen BD, Fernandes V, McClelland RL, et al.: Relationship between baseline coronary calcium score and demonstration of coronary artery stenoses during follow-up MESA (Multi-Ethnic Study of Atherosclerosis). JACC Cardiovasc Imaging 2009, 2:1175–1183.CrossRefPubMedGoogle Scholar
  26. 26.
    Di Carli MF: Hybrid imaging: integration of nuclear imaging and cardiac CT. Cardiol Clin 2009, 27:257–263.CrossRefPubMedGoogle Scholar
  27. 27.
    Kaufmann PA: Cardiac hybrid imaging: state-of-the-art. Ann Nucl Med 2009, 23:325–331.CrossRefPubMedGoogle Scholar
  28. 28.
    Kaufmann PA, Di Carli MF: Hybrid SPECT/CT and PET/CT imaging: the next step in noninvasive cardiac imaging. Semin Nucl Med 2009, 39:341–347.CrossRefPubMedGoogle Scholar
  29. 29.
    Knuuti J: Integrated positron emission tomography/computed tomography (PET/CT) in coronary disease. Heart 2009, 95:1457–1463.CrossRefPubMedGoogle Scholar
  30. 30.
    •• Rispler S, Keidar Z, Ghersin E, et al.: Integrated single-photon emission computed tomography and computed tomography coronary angiography for the assessment of hemodynamically significant coronary artery lesions. J Am Coll Cardiol 2007, 49:1059–1067. This paper discusses a study of 56 patients with angina who underwent single-session SPECT MPI and coronary CTA with a hybrid system and coronary angiography within 4 weeks. Hybrid SPECT/coronary CTA imaging resulted in improved specificity and positive predictive value to detect hemodynamically significant lesions in patients with chest pain.CrossRefPubMedGoogle Scholar
  31. 31.
    Shaw LJ, Berman DS, Maron DJ, et al.: Optimal medical therapy with or without percutaneous coronary intervention to reduce ischemic burden: results from the Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation (COURAGE) trial nuclear substudy. Circulation 2008, 117:1283–1291.CrossRefPubMedGoogle Scholar
  32. 32.
    Javadi M, Mahesh M, McBride G, et al.: Lowering radiation dose for integrated assessment of coronary morphology and physiology: first experience with step-and-shoot CT angiography in a rubidium 82 PET-CT protocol. J Nucl Cardiol 2008, 15:783–790.PubMedGoogle Scholar
  33. 33.
    Knuuti J: Cardiac hybrid imaging with low radiation dose. J Nucl Cardiol 2008, 15:743–744.PubMedGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC 2010

Authors and Affiliations

  • Bilal Ali
    • 1
  • Edward Hsiao
    • 1
  • Marcelo F. Di Carli
    • 1
  1. 1.Division of Nuclear Medicine and Molecular Imaging, Department of RadiologyBrigham and Women’s HospitalBostonUSA

Personalised recommendations