Myocardial Perfusion

  • Markus Weininger
  • U. Joseph Schoepf
  • Doo Kyoung Kang
  • Thomas Henzler
  • Balasz Ruzsics
Part of the Medical Radiology book series (MEDRAD)


Myocardial perfusion is an important prognostic marker in the management of patients with suspected coronary artery disease as it demonstrates the hemodynamic consequences of coronary artery stenosis. The traditional diagnostic algorithm is based on a combination of physiological and anatomical testing using different modalities. Physiological testing, such as nuclear imaging, has been extensively validated for determining the effect of stenoses on the myocardial perfusion but provides only limited anatomical information. Conversely, anatomical testing, such as invasive coronary angiography, can directly visualize and grade coronary artery stenosis but has limitations for gauging their hemodynamic effect on the myocardial perfusion.

Accordingly, a single test allowing the comprehensive evaluation of all aspects of coronary artery disease is clinically desirable. There is early evidence that cardiac computed tomography (CT) performed in single- or dual-energy mode has the potential for an integrative evaluation of both, coronary artery anatomy as well as changes in the myocardial blood supply. Cardiac dual-energy CT is based on the more recent technology of dual-source CT, and exploits the fact that iodine-based contrast medium has unique spectral characteristics when penetrated with different X-ray energy levels, enabling mapping of the iodine (and thus blood) distribution within the myocardium.

This chapter provides an overview about the role and current state of dual-energy CT in the evaluation of the myocardial perfusion.


Single Photon Emission Compute Tomography Myocardial Perfusion Myocardial Perfusion Imaging Coronary Artery Stenosis Invasive Coronary Angiography 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.


  1. Armstrong WF, Zoghbi WA (2005) Stress echocardiography: current methodology and clinical applications. J Am Coll Cardiol 45(11):1739–1747PubMedCrossRefGoogle Scholar
  2. Bastarrika G et al (2009) CT of coronary artery disease. Radiology 253(2):317–338PubMedCrossRefGoogle Scholar
  3. Brody WR et al (1981a) A method for selective tissue and bone visualization using dual energy scanned projection radiography. Med Phys 8(3):353–357PubMedCrossRefGoogle Scholar
  4. Brody WR et al (1981b) Dual-energy projection radiography: initial clinical experience. AJR Am J Roentgenol 137(2):201–205PubMedGoogle Scholar
  5. Cerqueira MD et al (2002) 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. Circulation 105(4):539–542PubMedCrossRefGoogle Scholar
  6. Chiro GD et al (1979) Tissue signatures with dual-energy computed tomography. Radiology 131(2):521–523PubMedGoogle Scholar
  7. Choi SI et al (2009) Recent developments in wide-detector cardiac computed tomography. Int J Cardiovasc Imaging 25(suppl 1):23–29PubMedCrossRefGoogle Scholar
  8. Coles DR et al (2006) Comparison of radiation doses from multislice computed tomography coronary angiography and conventional diagnostic angiography. J Am Coll Cardiol 47(9):1840–1845PubMedCrossRefGoogle Scholar
  9. Eichenberger AC et al (1994) Ischemic heart disease: assessment with gadolinium-enhanced ultrafast MR imaging and dipyridamole stress. J Magn Reson Imaging 4(3):425–431PubMedCrossRefGoogle Scholar
  10. Flohr TG et al (2006) First performance evaluation of a dual-source CT (DSCT) system. Eur Radiol 16(2):256–268PubMedCrossRefGoogle Scholar
  11. Gaemperli O et al (2007) Accuracy of 64-slice CT angiography for the detection of functionally relevant coronary stenoses as assessed with myocardial perfusion SPECT. Eur J Nucl Med Mol Imaging 34(8):1162–1171PubMedCrossRefGoogle Scholar
  12. Genant HK, Boyd D (1977) Quantitative bone mineral analysis using dual energy computed tomography. Invest Radiol 12(6):545–551PubMedCrossRefGoogle Scholar
  13. George RT et al (2006) Multidetector computed tomography myocardial perfusion imaging during adenosine stress. J Am Coll Cardiol 48(1):153–160PubMedCrossRefGoogle Scholar
  14. George RT et al (2009) Adenosine stress 64- and 256-row detector computed tomography angiography and perfusion imaging: a pilot study evaluating the transmural extent of perfusion abnormalities to predict atherosclerosis causing myocardial ischemia. Circ Cardiovasc Imaging 2(3):174–182PubMedCrossRefGoogle Scholar
  15. Gibbons RJ et al (2003) ACC/AHA 2002 guideline update for the management of patients with chronic stable angina–summary article: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guide­lines (Committee on the Management of Patients With Chronic Stable Angina). Circulation 107(1):149–158PubMedCrossRefGoogle Scholar
  16. Glover DK et al (1995) Comparison between 201Tl and 99mTc sestamibi uptake during adenosine-induced vasodilation as a function of coronary stenosis severity. Circulation 91(3):813–820PubMedCrossRefGoogle Scholar
  17. Gupta NC et al (1992) Comparison of adenosine and exercise thallium-201 single-photon emission computed tomography (SPECT) myocardial perfusion imaging. The GE SPECT Multicenter Adenosine Study Group. J Am Coll Cardiol 19(2):248–257PubMedCrossRefGoogle Scholar
  18. Hacker M et al (2005) Comparison of spiral multidetector CT angiography and myocardial perfusion imaging in the noninvasive detection of functionally relevant coronary artery lesions: first clinical experiences. J Nucl Med 46(8):1294–1300PubMedGoogle Scholar
  19. Hausleiter J et al (2006) Radiation dose estimates from cardiac multislice computed tomography in daily practice: impact of different scanning protocols on effective dose estimates. Circulation 113(10):1305–1310PubMedCrossRefGoogle Scholar
  20. Heijenbrok-Kal MH, Fleischmann KE, Hunink MG (2007) Stress echocardiography, stress single-photon-emission computed tomography and electron beam computed tomography for the assessment of coronary artery disease: a meta-analysis of diagnostic performance. Am Heart J 154(3):415–423PubMedCrossRefGoogle Scholar
  21. Hendel RC et al (2006) ACCF/ACR/SCCT/SCMR/ASNC/NASCI/SCAI/SIR 2006 appropriateness criteria for cardiac computed tomography and cardiac magnetic resonance imaging: a report of the American College of Cardiology Foundation Quality Strategic Directions Committee Appropriateness Criteria Working Group, American College of Radiology, Society of Cardiovascular Computed Tomography, Society for Cardiovascular Magnetic Resonance, American Society of Nuclear Cardiology, North American Society for Cardiac Imaging, Society for Cardiovascular Angiography and Interventions, and Society of Interventional Radiology. J Am Coll Cardiol 48(7):1475–1497PubMedCrossRefGoogle Scholar
  22. Hendel RC et al (2009) ACCF/ASNC/ACR/AHA/ASE/SCCT/SCMR/SNM 2009 appropriate use criteria for cardiac radionuclide imaging: a report of the American College of Cardiology Foundation Appropriate Use Criteria Task Force, the American Society of Nuclear Cardiology, the American College of Radiology, the American Heart Association, the American Society of Echocardiography, the Society of Cardiovascular Computed Tomography, the Society for Cardiovascular Magnetic Resonance, and the Society of Nuclear Medicine: endorsed by the American College of Emergency Physicians. Circulation 119(22):e561–e587PubMedCrossRefGoogle Scholar
  23. Heuschmid M et al (2007) Usefulness of noninvasive cardiac imaging using dual-source computed tomography in an unselected population with high prevalence of coronary artery disease. Am J Cardiol 100(4):587–592PubMedCrossRefGoogle Scholar
  24. Heymann MA et al (1977) Blood flow measurements with radionuclide-labeled particles. Prog Cardiovasc Dis 20(1):55–79PubMedCrossRefGoogle Scholar
  25. Jahnke C et al (2007) Prognostic value of cardiac magnetic resonance stress tests: adenosine stress perfusion and dobutamine stress wall motion imaging. Circulation 115(13):1769–1776PubMedCrossRefGoogle Scholar
  26. Johnson TR et al (2007a) Diagnostic accuracy of dual-source computed tomography in the diagnosis of coronary artery disease. Invest Radiol 42(10):684–691PubMedCrossRefGoogle Scholar
  27. Johnson TR et al (2007b) Material differentiation by dual energy CT: initial experience. Eur Radiol 17(6):1510–1517PubMedCrossRefGoogle Scholar
  28. Kalender WA et al (1986) Evaluation of a prototype dual-energy computed tomographic apparatus. I. Phantom studies. Med Phys 13(3):334–339PubMedCrossRefGoogle Scholar
  29. Klocke FJ et al (2003) 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 42(7):1318–1333PubMedCrossRefGoogle Scholar
  30. Leber AW et al (2007) Diagnostic accuracy of dual-source multi-slice CT-coronary angiography in patients with an intermediate pretest likelihood for coronary artery disease. Eur Heart J 28(19):2354–2360PubMedCrossRefGoogle Scholar
  31. Lell M et al (2009) Prospectively ECG-triggered high-pitch spiral acquisition for coronary CT angiography using dual source CT: technique and initial experience. Eur Radiol 19(11):2576–2583PubMedCrossRefGoogle Scholar
  32. Leschka S et al (2009) Diagnostic accuracy of high-pitch dual-source CT for the assessment of coronary stenoses: first experience. Eur Radiol 19(12):2896–2903PubMedCrossRefGoogle Scholar
  33. Lloyd-Jones D et al (2009) Heart disease and stroke statistics – 2010 update. A report from the American Heart Association. Circulation 121(7):e46–e215PubMedGoogle Scholar
  34. Maddahi J et al (1994) State-of-the-art myocardial perfusion imaging. Cardiol Clin 12(2):199–222PubMedGoogle Scholar
  35. Manning WJ et al (1991) First-pass nuclear magnetic resonance imaging studies using gadolinium-DTPA in patients with coronary artery disease. J Am Coll Cardiol 18(4):959–965PubMedCrossRefGoogle Scholar
  36. Marcassa C et al (2008) Clinical value, cost-effectiveness, and safety of myocardial perfusion scintigraphy: a position statement. Eur Heart J 29(4):557–563PubMedCrossRefGoogle Scholar
  37. Meijboom WB et al (2008a) Diagnostic accuracy of 64-slice computed tomography coronary angiography: a prospective, multicenter, multivendor study. J Am Coll Cardiol 52(25):2135–2144PubMedCrossRefGoogle Scholar
  38. Meijboom WB et al (2008b) Comprehensive assessment of coronary artery stenoses: computed tomography coronary angiography versus conventional coronary angiography and correlation with fractional flow reserve in patients with stable angina. J Am Coll Cardiol 52(8):636–643PubMedCrossRefGoogle Scholar
  39. Merkle N et al (2007) Assessment of myocardial perfusion for detection of coronary artery stenoses by steady-state, free-precession magnetic resonance first-pass imaging. Heart 93(11):1381–1385PubMedCrossRefGoogle Scholar
  40. Mettler FA Jr et al (2008) Effective doses in radiology and ­diagnostic nuclear medicine: a catalog. Radiology 248(1):254–263PubMedCrossRefGoogle Scholar
  41. Miller DD, Verani MS (1994) Current status of myocardial perfusion imaging after percutaneous transluminal coronary angioplasty. J Am Coll Cardiol 24(1):260–266PubMedCrossRefGoogle Scholar
  42. Murray CJ, Lopez AD (1997a) Global mortality, disability, and the contribution of risk factors: Global Burden of Disease Study. Lancet 349(9063):1436–1442PubMedCrossRefGoogle Scholar
  43. Murray CJ, Lopez AD (1997b) Mortality by cause for eight regions of the world: Global Burden of Disease Study. Lancet 349(9061):1269–1276PubMedCrossRefGoogle Scholar
  44. Nagao M et al (2008) Quantification of myocardial perfusion by contrast-enhanced 64-MDCT: characterization of ischemic myocardium. AJR Am J Roentgenol 191(1):19–25PubMedCrossRefGoogle Scholar
  45. Nagao M et al (2009) Detection of myocardial ischemia using 64-slice MDCT. Circ J 73(5):905–911PubMedCrossRefGoogle Scholar
  46. Nagel E et al (1999) Noninvasive diagnosis of ischemia-induced wall motion abnormalities with the use of high-dose ­dobutamine stress MRI: comparison with dobutamine stress echocardiography. Circulation 99(6):763–770PubMedCrossRefGoogle Scholar
  47. Namdar M et al (2005) Integrated PET/CT for the assessment of coronary artery disease: a feasibility study. J Nucl Med 46(6):930–935PubMedGoogle Scholar
  48. Nguyen T et al (1990) Single photon emission computed tomography with thallium-201 during adenosine-induced coronary hyperemia: correlation with coronary arteriography, exercise thallium imaging and two-dimensional echocardiography. J Am Coll Cardiol 16(6):1375–1383PubMedCrossRefGoogle Scholar
  49. Ohnesorge B et al (2000) Cardiac imaging by means of electrocardiographically gated multisection spiral CT: initial experience. Radiology 217(2):564–571PubMedGoogle Scholar
  50. Petersilka M et al (2008) Technical principles of dual source CT. Eur J Radiol 68(3):362–368PubMedCrossRefGoogle Scholar
  51. Riederer SJ, Mistretta CA (1977) Selective iodine imaging using K-edge energies in computerized X-ray tomography. Med Phys 4(6):474–481PubMedCrossRefGoogle Scholar
  52. Rispler S et al (2007) Integrated single-photon emission computed tomography and computed tomography coronary angiography for the assessment of hemodynamically significant coronary artery lesions. J Am Coll Cardiol 49(10):1059–1067PubMedCrossRefGoogle Scholar
  53. Ruzsics B et al (2008a) Images in cardiovascular medicine. Myocardial ischemia diagnosed by dual-energy computed tomography: correlation with single-photon emission computed tomography. Circulation 117(9):1244–1245PubMedCrossRefGoogle Scholar
  54. Ruzsics B et al (2008b) Dual-energy CT of the heart for diagnosing coronary artery stenosis and myocardial ischemia-initial experience. Eur Radiol 18(11):2414–2424PubMedCrossRefGoogle Scholar
  55. Ruzsics B, Chiaramida SA, Schoepf UJ (2009a) Images in cardiology: dual-energy computed tomography imaging of myocardial infarction. Heart 95(3):180PubMedCrossRefGoogle Scholar
  56. Ruzsics B et al (2009b) Comparison of dual-energy computed tomography of the heart with single photon emission computed tomography for assessment of coronary artery stenosis and of the myocardial blood supply. Am J Cardiol 104(3):318–326PubMedCrossRefGoogle Scholar
  57. Schuijf JD et al (2006) Relationship between noninvasive coronary angiography with multi-slice computed tomography and myocardial perfusion imaging. J Am Coll Cardiol 48(12):2508–2514PubMedCrossRefGoogle Scholar
  58. Schwarz F et al (2008) Dual-energy CT of the heart–principles and protocols. Eur J Radiol 68(3):423–433PubMedCrossRefGoogle Scholar
  59. Schwitter J et al (2001) Assessment of myocardial perfusion in coronary artery disease by magnetic resonance: a comparison with positron emission tomography and coronary angiography. Circulation 103(18):2230–2235PubMedCrossRefGoogle Scholar
  60. Schwitter J et al (2008) 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 29(4):480–489PubMedCrossRefGoogle Scholar
  61. Thilo C et al (2009) Integrated assessment of coronary anatomy and myocardial perfusion using a retractable SPECT camera combined with 64-slice CT: initial experience. Eur Radiol 19(4):845–856PubMedCrossRefGoogle Scholar
  62. Vetter JR et al (1986) Evaluation of a prototype dual-energy computed tomographic apparatus. II. Determination of vertebral bone mineral content. Med Phys 13(3):340–343PubMedCrossRefGoogle Scholar
  63. Wilke N et al (1997) Myocardial perfusion reserve: assessment with multisection, quantitative, first-pass MR imaging. Radi­ology 204(2):373–384PubMedGoogle Scholar

Copyright information

© Springer-Verlag Berlin Heidelberg 2011

Authors and Affiliations

  • Markus Weininger
    • 1
  • U. Joseph Schoepf
    • 1
    • 2
  • Doo Kyoung Kang
    • 3
  • Thomas Henzler
    • 1
    • 4
  • Balasz Ruzsics
    • 1
  1. 1.Department of Radiology and Radiological ScienceMedical University of South CarolinaCharlestonUSA
  2. 2.Department of Medicine, Division of CardiologyMedical University of South CarolinaCharlestonUSA
  3. 3.Department of RadiologyAjou University HospitalSuwonSouth Korea
  4. 4.Department of Clinical Radiology and Nuclear MedicineUniversity Medical Center Mannheim, Medical Faculty Mannheim of the University of HeidelbergMannheimGermany

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