Journal of Nuclear Cardiology

, Volume 16, Issue 4, pp 549–561 | Cite as

Noninvasive stress testing of myocardial perfusion defects: head-to-head comparison of thallium-201 SPECT to MRI perfusion

  • Gabriella Vincenti
  • René Nkoulou
  • Charles Steiner
  • Hestia Imperiano
  • Giuseppe Ambrosio
  • François Mach
  • Osman Ratib
  • Jean-Paul Vallee
  • Thomas H. SchindlerEmail author
Original Article



To evaluate the diagnostic value of magnetic resonance imaging (MRI) of myocardial perfusion in the assessment of flow-limiting epicardial stenosis in a head-to-head comparison with abnormal thallium-201 (201TI) single photon emission tomography (SPECT) studies in patients with predominantly known coronary artery disease (CAD).

Methods and Results

Twenty-one patients (mean age 65 ± 10 years) with reversible myocardial perfusion defects on 201TI-SPECT images during dipyridamole-stimulated hyperemia were recruited for study purpose. Within 5 days of the 201TI-SPECT study, myocardial perfusion was studied again with MRI during dipyridamole stimulation and at rest. Overall, 201TI-SPECT identified 30 reversible regional perfusion defects. The sensitivity to detect hypoperfused segments was 70% (21/30) with the GRE-MRI perfusion analysis with 201TI-SPECT as reference. When patients were subgrouped according to the extent of regional reversible perfusion defects on 201TI-SPECT, mild- (SDS: 2-4), moderate- (SDS: 5-8), and severe- (SDS > 8) perfusion defects were also identified by GRE-MRI perfusion analysis in 75% (6/8), in 56% (9/16) and 100% (6/6), respectively.


GRE-MRI first-pass stress perfusion imaging may not identify up to 30% of mild-to-moderate perfusion defects in a group of preselected patients with predominantly known CAD and abnormal 201TI-SPECT studies.


Cardiac imaging coronary artery disease ischemia MRI SPECT 



This work was supported by a clinical research grant of the Department of Internal Medicine of the University Hospitals of Geneva (Switzerland), by a Atherothrombosis Research Fellowship Grant for Dr. G. Vincenti from the European Society of Cardiology (ESC) and the Italian Society of Cardiology (Società Italiana di Cardiologie), and with the support of the Swiss National Science Foundation (SNF grant: PP00B-116901-1).


  1. 1.
    Nesto RW, Kowalchuk GJ. The ischemic cascade: Femporal sequence of hemodynamic, electrocardiographic and symptomatic expressions of ischemia. Am J Cardiol 1987;59(7):23C–30C.CrossRefPubMedGoogle Scholar
  2. 2.
    Marwick TH. Current status of stress echocardiography for diagnosis and prognostic assessment of coronary artery disease. Coron Artery Dis 1998;9(7):411–26.CrossRefPubMedGoogle Scholar
  3. 3.
    Geleijnse ML, Elhendy A. Can stress echocardiography compete with perfusion scintigraphy in the detection of coronary artery disease and cardiac risk assessment? Eur J Echocardiogr 2000;1(1):12–21.CrossRefPubMedGoogle Scholar
  4. 4.
    Nandalur KR, Dwamena BA, Choudhri AF, Nandalur MR, Carlos RC. Diagnostic performance of stress cardiac magnetic resonance imaging in the detection of coronary artery disease: a meta-analysis. J Am Coll Cardiol 2007;50(14):1343–53.CrossRefPubMedGoogle Scholar
  5. 5.
    Bax JJ, Van der Wall EE, de Roos A, Poldermans D. Comparison with non-nuclear techniques. In: Zaret BL, Beller GA, editors. Nuclear cardiology—state of the art and future directions. Mosby: Philadelphia; 2005. p. 535-55.Google Scholar
  6. 6.
    Jerosch-Herold M, Kwong RY. Optimal imaging strategies to assess coronary blood flow and risk for patients with coronary artery disease. Curr Opin Cardiol 2008;23(6):599–606.CrossRefPubMedGoogle Scholar
  7. 7.
    Schindler TH, Schelbert HR. Quantification of myocardial blood flow. In: Dilsizian V, Narula J, Braunwald E, editors. Atlas of nuclear cardiology. Current Medecine LLC; 2006. p. 68-95.Google Scholar
  8. 8.
    Verna E, Ceriani L, Provasoli S, Scotti S, Ghiringhelli S. Larger perfusion defects with exercise compared with dipyridamole SPECT (exercise-dipyridamole mismatch) may reflect differences in epicardial and microvascular coronary dysfunction: When the stressor matters. J Nucl Cardiol 2007;14(6):818–26.CrossRefPubMedGoogle Scholar
  9. 9.
    Gould KL. Assessing progression or regression of CAD: The role of perfusion imaging. J Nucl Cardiol 2005;12(6):625–38.CrossRefPubMedGoogle Scholar
  10. 10.
    Schindler TH, Schelbert HR. “Mismatch” in regional myocardial perfusion defects during exercise and pharmacologic vasodilation: A noninvasive marker of epicardial vasomotor dysfunction? J Nucl Cardiol 2007;14(6):769–74.CrossRefPubMedGoogle Scholar
  11. 11.
    Gould KL, Nakagawa Y, Nakagawa K, Sdringola S, Hess MJ, Haynie M, et al. Frequency and clinical implications of fluid dynamically significant diffuse coronary artery disease manifest as graded, longitudinal, base-to-apex myocardial perfusion abnormalities by noninvasive positron emission tomography. Circulation 2000;101(16):1931–9.PubMedGoogle Scholar
  12. 12.
    Schindler TH, Facta AD, Prior JO, Cadenas J, Zhang XL, Li Y, et al. Structural alterations of the coronary arterial wall are associated with myocardial flow heterogeneity in type 2 diabetes mellitus. Eur J Nucl Med Mol Imaging 2008;36:219–29.CrossRefPubMedGoogle Scholar
  13. 13.
    Wolak A, Slomka PJ, Fish MB, Lorenzo S, Berman DS, Germano G. Quantitative diagnostic performance of myocardial perfusion SPECT with attenuation correction in women. J Nucl Med 2008;49(6):915–22.CrossRefPubMedGoogle Scholar
  14. 14.
    Berman DS, Hachamovitch R, Kiat H, Cohen I, Cabico JA, Wang FP, et al. Incremental value of prognostic testing in patients with known or suspected ischemic heart disease: a basis for optimal utilization of exercise technetium-99 m sestamibi myocardial perfusion single-photon emission computed tomography. J Am Coll Cardiol 1995;26(3):639–47.CrossRefPubMedGoogle Scholar
  15. 15.
    Cerqueira MD, Weissman NJ, Dilsizian V, Jacobs AK, Kaul S, Laskey WK, et al. Standardized myocardial segmentation and nomenclature for tomographic imaging of the heart: A statement for healthcare professionals from the Cardiac Imaging Committee of the Council on Clinical Cardiology of the American Heart Association. J Nucl Cardiol 2002;9(2):240–5.CrossRefPubMedGoogle Scholar
  16. 16.
    Schwitter J, Wacker CM, van Rossum AC, Lombardi M, Al-Saadi N, Ahlstrom H, et al. MR-IMPACT: Comparison of perfusion-cardiac magnetic resonance with single-photon emission computed tomography for the detection of coronary artery disease in a multicentre, multivendor, randomized trial. Eur Heart J 2008;29(4):480–9.CrossRefPubMedGoogle Scholar
  17. 17.
    Wu E, Judd RM, Vargas JD, Klocke FJ, Bonow RO, Kim RJ. Visualisation of presence, location, and transmural extent of healed Q-wave and non-Q-wave myocardial infarction. Lancet 2001;357(9249):21–8.CrossRefPubMedGoogle Scholar
  18. 18.
    Bremerich J, Buser P, Bongartz G, Muller-Brand J, Gradel C, Pfisterer M, et al. Noninvasive stress testing of myocardial ischemia: Comparison of GRE-MRI perfusion and wall motion analysis to 99 mTc-MIBI-SPECT, relation to coronary angiography. Eur Radiol 1997;7(7):990–5.CrossRefPubMedGoogle Scholar
  19. 19.
    Glover DK, Ruiz M, Edwards NC, Cunningham M, Simanis JP, Smith WH, et al. Comparison between 201Tl and 99mTc sestamibi uptake during adenosine-induced vasodilation as a function of coronary stenosis severity. Circulation 1995;91(3):813–20.PubMedGoogle Scholar
  20. 20.
    Brasch RC. New directions in the development of MR imaging contrast media. Radiology 1992;183(1):1–11.PubMedGoogle Scholar
  21. 21.
    Panting JR, Gatehouse PD, Yang GZ, Grothues F, Firmin DN, Collins P, et al. Abnormal subendocardial perfusion in cardiac syndrome X detected by cardiovascular magnetic resonance imaging. N Engl J Med 2002;346(25):1948–53.CrossRefPubMedGoogle Scholar
  22. 22.
    Wang L, Jerosch-Herold M, Jacobs DR Jr, Shahar E, Detrano R, Folsom AR. Coronary artery calcification and myocardial perfusion in asymptomatic adults: The MESA (Multi-Ethnic Study of Atherosclerosis). J Am Coll Cardiol 2006;48(5):1018–26.CrossRefPubMedGoogle Scholar
  23. 23.
    Di Carli MF, Dorbala S, Hachamovitch R. Integrated cardiac PET-CT for the diagnosis and management of CAD. J Nucl Cardiol 2006;13(2):139–44.PubMedGoogle Scholar
  24. 24.
    Beller GA. Underestimation of coronary artery disease with SPECT perfusion imaging. J Nucl Cardiol 2008;15(2):151–3.CrossRefPubMedGoogle Scholar
  25. 25.
    Dorbala S, Vangala D, Sampson U, Limaye A, Kwong R, Di Carli MF. 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(3):349–58.PubMedGoogle Scholar
  26. 26.
    Slomka PJ, Fish MB, Lorenzo S, Nishina H, Gerlach J, Berman DS, et al. Simplified normal limits and automated quantitative assessment for attenuation-corrected myocardial perfusion SPECT. J Nucl Cardiol 2006;13(5):642–51.CrossRefPubMedGoogle Scholar
  27. 27.
    Sakuma H, Suzawa N, Ichikawa Y, Makino K, Hirano T, Kitagawa K, et al. Diagnostic accuracy of stress first-pass contrast-enhanced myocardial perfusion MRI compared with stress myocardial perfusion scintigraphy. AJR Am J Roentgenol 2005;185(1):95–102.PubMedGoogle Scholar
  28. 28.
    Beller GA. Assessment of new technologies: Surrogate endpoints versus outcomes, and the cost of health care. J Nucl Cardiol 2008;15(3):299–300.CrossRefPubMedGoogle Scholar
  29. 29.
    Hachamovitch R, Di Carli MF. Methods and limitations of assessing new noninvasive tests: Part II: Outcomes-based validation and reliability assessment of noninvasive testing. Circulation 2008;117(21):2793–801.CrossRefPubMedGoogle Scholar
  30. 30.
    Hachamovitch R, Di Carli MF. Methods and limitations of assessing new noninvasive tests: Part I: Anatomy-based validation of noninvasive testing. Circulation 2008;117(20):2684–90.CrossRefPubMedGoogle Scholar
  31. 31.
    Sato A, Hiroe M, Tamura M, Ohigashi H, Nozato T, Hikita H, et al. Quantitative measures of coronary stenosis severity by 64-Slice CT angiography and relation to physiologic significance of perfusion in nonobese patients: comparison with stress myocardial perfusion imaging. J Nucl Med 2008;49(4):564–72.CrossRefPubMedGoogle Scholar
  32. 32.
    Kern MJ. Coronary physiology revisited: Practical insights from the cardiac catheterization laboratory. Circulation 2000;101(11):1344–51.PubMedGoogle Scholar
  33. 33.
    Gerber BL, Raman SV, Nayak K, Epstein FH, Ferreira P, Axel L, et al. Myocardial first-pass perfusion cardiovascular magnetic resonance: History, theory, and current state of the art. J Cardiovasc Magn Reson 2008;10(1):18.CrossRefPubMedGoogle Scholar
  34. 34.
    Klem I, Heitner JF, Shah DJ, Sketch MH Jr, Behar V, Weinsaft J, et al. Improved detection of coronary artery disease by stress perfusion cardiovascular magnetic resonance with the use of delayed enhancement infarction imaging. J Am Coll Cardiol 2006;47(8):1630–8.CrossRefPubMedGoogle Scholar
  35. 35.
    Nagel E, Klein C, Paetsch I, Hettwer S, Schnackenburg B, Wegscheider K, et al. Magnetic resonance perfusion measurements for the noninvasive detection of coronary artery disease. Circulation 2003;108(4):432–7.CrossRefPubMedGoogle Scholar
  36. 36.
    Schwitter J, Nanz D, Kneifel S, Bertschinger K, Buchi M, Knusel PR, et al. Assessment of myocardial perfusion in coronary artery disease by magnetic resonance: A comparison with positron emission tomography and coronary angiography. Circulation 2001;103(18):2230–5.PubMedGoogle Scholar
  37. 37.
    Rieber J, Huber A, Erhard I, Mueller S, Schweyer M, Koenig A, et al. Cardiac magnetic resonance perfusion imaging for the functional assessment of coronary artery disease: A comparison with coronary angiography and fractional flow reserve. Eur Heart J 2006;27(12):1465–71.CrossRefPubMedGoogle Scholar
  38. 38.
    Schwitter J. Myocardial perfusion imaging by cardiac magnetic resonance. J Nucl Cardiol 2006;13(6):841–54.CrossRefPubMedGoogle Scholar

Copyright information

© American Society of Nuclear Cardiology 2009

Authors and Affiliations

  • Gabriella Vincenti
    • 1
  • René Nkoulou
    • 1
  • Charles Steiner
    • 2
  • Hestia Imperiano
    • 2
  • Giuseppe Ambrosio
    • 4
  • François Mach
    • 1
  • Osman Ratib
    • 2
  • Jean-Paul Vallee
    • 3
  • Thomas H. Schindler
    • 1
    Email author
  1. 1.Department of Internal Medicine, Cardiovascular Center, Nuclear Cardiology University Hospital of GenevaGenevaSwitzerland
  2. 2.Department of Radiology, Division of Nuclear MedicineUniversity Hospital of GenevaGenevaSwitzerland
  3. 3.Department of RadiologyUniversity Hospital of GenevaGenevaSwitzerland
  4. 4.Division of CardiologyUniversity Hospital of PerugiaPerugiaItaly

Personalised recommendations