Why Are We Interested in Myocardial Perfusion?

Part of the Medical Radiology book series (MEDRAD)


Cardiac CTA is increasingly asserting its position as an established tool for the detection and characterization of coronary plaque and stenosis, its morphological evaluation capability, however, falling short of hemodynamic assessment. This fact is of high relevance in the process of therapeutic decision making, which explains the dominance of functional imaging techniques, such as nuclear myocardial perfusion imaging, magnetic resonance imaging, or stress echocardiography. There are four major targets of functional imaging that are particularly critical to the selection of a revascularization procedure over medical treatment strategies: (1) Assessment of myocardial perfusion defects to identify treatable coronary artery disease (CAD); (2) Identification of myocardial perfusion status as an important prognostic factor for the occurrence of future cardiovascular events; (3) Assessment of myocardial viability to guide therapy; and (4) Evaluation of the hemodynamic relevance of detected coronary artery stenosis by flow measurements. This chapter reviews the current limitations of morphological assessment of coronary stenosis by cardiac CTA, describes available techniques for functional imaging, and enumerates its major targets, which have been well implemented in current management strategies for patients with suspected or known CAD.


Myocardial Perfusion Cardiac Magnetic Resonance Late Gadolinium Enhancement Perfusion Defect Fractional Flow Reserve 
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. Aarnoudse WH, Botman KJ, Pijls NH (2003) False-negative myocardial scintigraphy in balanced three-vessel disease, revealed by coronary pressure measurement. Int J Cardiovasc Intervent 5(2):67–71PubMedGoogle Scholar
  2. Achenbach S et al (2010) The year in coronary artery disease. JACC Cardiovasc Imaging 3(10):1065–1077PubMedCrossRefGoogle Scholar
  3. Allman KC et al (2002) Myocardial viability testing and impact of revascularization on prognosis in patients with coronary artery disease and left ventricular dysfunction: a meta-analysis. J Am Coll Cardiol 39(7):1151–1158PubMedCrossRefGoogle Scholar
  4. Berman DS et al (2006) Roles of nuclear cardiology, cardiac computed tomography, and cardiac magnetic resonance: assessment of patients with suspected coronary artery disease. J Nucl Med 47(1):74–82PubMedGoogle Scholar
  5. Boden WE et al (2007) Optimal medical therapy with or without PCI for stable coronary disease. N Engl J Med 356(15):1503–1516PubMedCrossRefGoogle Scholar
  6. Bodi V et al (2007) Prognostic value of dipyridamole stress cardiovascular magnetic resonance imaging in patients with known or suspected coronary artery disease. J Am Coll Cardiol 50(12):1174–1179PubMedCrossRefGoogle Scholar
  7. Bonow RO et al (1985) Asynchronous left ventricular regional function and impaired global diastolic filling in patients with coronary artery disease: reversal after coronary angioplasty. Circulation 71(2):297–307PubMedCrossRefGoogle Scholar
  8. Brown KA et al (1983) Prognostic value of exercise thallium-201 imaging in patients presenting for evaluation of chest pain. J Am Coll Cardiol 1(4):994–1001PubMedCrossRefGoogle Scholar
  9. Cerci MS et al (2011) Myocardial perfusion imaging is a strong predictor of death in women. JACC Cardiovasc Imaging 4(8):880–888PubMedCrossRefGoogle Scholar
  10. 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
  11. Cheong BY (2010) Cardiovascular magnetic resonance imaging and computed tomography. Tex Heart Inst J 37(3):316–318PubMedGoogle Scholar
  12. Choi KM et al (2001) Transmural extent of acute myocardial infarction predicts long-term improvement in contractile function. Circulation 104(10):1101–1107PubMedCrossRefGoogle Scholar
  13. Christiansen JP et al (2010) Stress perfusion imaging using cardiovascular magnetic resonance: a review. Heart Lung Circ 19(12):697–705PubMedCrossRefGoogle Scholar
  14. Croisille P, Revel D, Saeed M (2006) Contrast agents and cardiac MR imaging of myocardial ischemia: from bench to bedside. Eur Radiol 16(9):1951–1963PubMedCrossRefGoogle Scholar
  15. Donahue KM, Weisskoff RM, Burstein D (1997) Water diffusion and exchange as they influence contrast enhancement. J Magn Reson Imaging 7(1):102–110PubMedCrossRefGoogle Scholar
  16. Ehring T, Heusch G (1990) Left ventricular asynchrony: an indicator of regional myocardial dysfunction. Am Heart J 120(5):1047–1057PubMedCrossRefGoogle Scholar
  17. Elhendy A et al (2000) Accuracy of exercise stress technetium 99 m sestamibi SPECT imaging in the evaluation of the extent and location of coronary artery disease in patients with an earlier myocardial infarction. J Nucl Cardiol 7(5):432–438PubMedCrossRefGoogle Scholar
  18. Garcia EV, Faber TL, Esteves FP (2011) Cardiac dedicated ultrafast SPECT cameras: new designs and clinical implications. J Nucl Med 52(2):210–217PubMedCrossRefGoogle Scholar
  19. Gould KL, Lipscomb K (1974) Effects of coronary stenoses on coronary flow reserve and resistance. Am J Cardiol 34(1):48–55PubMedCrossRefGoogle Scholar
  20. Hachamovitch R et al (1998) Incremental prognostic value of myocardial perfusion single photon emission computed tomography for the prediction of cardiac death: differential stratification for risk of cardiac death and myocardial infarction. Circulation 97(6):535–543PubMedCrossRefGoogle Scholar
  21. Hachamovitch R et al (2003) Comparison of the short-term survival benefit associated with revascularization compared with medical therapy in patients with no prior coronary artery disease undergoing stress myocardial perfusion single photon emission computed tomography. Circulation 107(23):2900–2907PubMedCrossRefGoogle Scholar
  22. Hacker M et al (2007) Sixty-four slice spiral CT angiography does not predict the functional relevance of coronary artery stenoses in patients with stable angina. Eur J Nucl Med Mol Imaging 34(1):4–10PubMedCrossRefGoogle Scholar
  23. Hoffmann U, Truong QA, Schoenfeld DA, Chou ET, Woodard PK, Nagurney JT, Pope JH, Hauser TH, White CS, Weiner SG, Kalanjian S, Mullins ME, Mikati I, Peacock WF, Zakroysky P, Hayden D, Goehler A, Lee H, Gazelle GS, Wiviott SD, Fleg JL, Udelson JE (2012) ROMICAT-II Investigators. N Engl J Med 367(4):299–308. doi: 10.1056/NEJMoa1201161 PubMedCrossRefGoogle Scholar
  24. Hundley WG et al (1998) Administration of an intravenous perfluorocarbon contrast agent improves echocardiographic determination of left ventricular volumes and ejection fraction: comparison with cine magnetic resonance imaging. J Am Coll Cardiol 32(5):1426–1432PubMedCrossRefGoogle Scholar
  25. Ingkanisorn WP et al (2006) Prognosis of negative adenosine stress magnetic resonance in patients presenting to an emergency department with chest pain. J Am Coll Cardiol 47(7):1427–1432PubMedCrossRefGoogle Scholar
  26. Ishii K et al (2009) Exercise-induced post-ischemic left ventricular delayed relaxation or diastolic stunning: is it a reliable marker in detecting coronary artery disease? J Am Coll Cardiol 53(8):698–705PubMedCrossRefGoogle Scholar
  27. Kapur A et al (2002) A comparison of three radionuclide myocardial perfusion tracers in clinical practice: the ROBUST study. Eur J Nucl Med Mol Imaging 29(12):1608–1616PubMedCrossRefGoogle Scholar
  28. Kim RJ et al (2000) The use of contrast-enhanced magnetic resonance imaging to identify reversible myocardial dysfunction. N Engl J Med 343(20):1445–1453PubMedCrossRefGoogle Scholar
  29. Klem I et al (2006) Improved detection of coronary artery disease by stress perfusion cardiovascular magnetic resonance with the use of delayed enhancement infarction imaging. J Am Coll Cardiol 47(8):1630–1638PubMedCrossRefGoogle Scholar
  30. Kruip MJHA et al (2003) Diagnostic strategies for excluding pulmonary embolism in clinical outcome studies—a systematic review. Ann Intern Med 138(12):941–951PubMedCrossRefGoogle Scholar
  31. Ladenheim ML et al (1986) Extent and severity of myocardial hypoperfusion as predictors of prognosis in patients with suspected coronary artery disease. J Am Coll Cardiol 7(3):464–471PubMedCrossRefGoogle Scholar
  32. Leong-Poi H et al (2002) Perfusion versus function: the ischemic cascade in demand ischemia: implications of single-vessel versus multivessel stenosis. Circulation 105(8):987–992PubMedCrossRefGoogle Scholar
  33. Leppo JA (1995) Preoperative cardiac risk assessment for noncardiac surgery. Am J Cardiol 75(11):42D–51DPubMedCrossRefGoogle Scholar
  34. Marcus RP et al (2011) Myocardial perfusion imaging by computed tomography: today and tomorrow. Int J Clin Pract Suppl 173:14–22PubMedCrossRefGoogle Scholar
  35. Mark DB et al (2003) 34th Bethesda conference: task force #5–is atherosclerosis imaging cost effective? J Am Coll Cardiol 41(11):1906–1917PubMedCrossRefGoogle Scholar
  36. Marwick TH (2006) Measurement of strain and strain rate by echocardiography: ready for prime time? J Am Coll Cardiol 47(7):1313–1327PubMedCrossRefGoogle Scholar
  37. Meijboom WB et al (2008) 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
  38. Merhige ME et al (2007) Impact of myocardial perfusion imaging with PET and (82)Rb on downstream invasive procedure utilization, costs, and outcomes in coronary disease management. J Nucl Med 48(7):1069–1076PubMedCrossRefGoogle Scholar
  39. Mertes H et al (1993) Symptoms, adverse effects, and complications associated with dobutamine stress echocardiography. Experience in 1118 patients. Circulation 88(1):15–19PubMedCrossRefGoogle Scholar
  40. Min JK, Berman D (2009) Anatomic and functional assessment of coronary artery disease: convergence of 2 aims in a single setting. Circ Cardiovasc Imaging 2(3):163–165PubMedCrossRefGoogle Scholar
  41. Nandalur KR et al (2007) Diagnostic performance of stress cardiac magnetic resonance imaging in the detection of coronary artery disease: a meta-analysis. J Am Coll Cardiol 50(14):1343–1353PubMedCrossRefGoogle Scholar
  42. Nesto RW, Kowalchuk GJ (1987) The ischemic cascade: temporal sequence of hemodynamic, electrocardiographic and symptomatic expressions of ischemia. Am J Cardiol 59(7):23C–30CPubMedCrossRefGoogle Scholar
  43. Pijls NH et al (2010) Fractional flow reserve versus angiography for guiding percutaneous coronary intervention in patients with multivessel coronary artery disease: 2-year follow-up of the FAME (fractional flow reserve versus angiography for multivessel evaluation) study. J Am Coll Cardiol 56(3):177–184PubMedCrossRefGoogle Scholar
  44. Rochmis P, Blackburn H (1971) Exercise tests. a survey of procedures, safety, and litigation experience in approximately 170,000 tests. JAMA 217(8):1061–1066PubMedCrossRefGoogle Scholar
  45. Roger VL et al (2011) Heart disease and stroke statistics–2011 update: a report from the American Heart Association. Circulation 123(4):e18–e209PubMedCrossRefGoogle Scholar
  46. Schinkel AF et al (2007) Assessment of myocardial viability in patients with heart failure. J Nucl Med 48(7):1135–1146PubMedCrossRefGoogle Scholar
  47. Schuijf JD, Bax JJ (2008) Defining noninvasive imaging strategies in coronary artery disease: Which patients require further evaluation after coronary angiography with multislice computed tomography? J Nucl Cardiol 15(3):301–304PubMedCrossRefGoogle Scholar
  48. Schuijf JD et al (2005) Cardiac imaging in coronary artery disease: differing modalities. Heart 91(8):1110–1117PubMedCrossRefGoogle Scholar
  49. Schuijf JD, Bax JJ, van der Wall EE (2007) Anatomical and functional imaging techniques: basically similar or fundamentally different? Neth Heart J 15(2):43–44PubMedCrossRefGoogle Scholar
  50. 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
  51. Selvanayagam JB et al (2004) Value of delayed-enhancement cardiovascular magnetic resonance imaging in predicting myocardial viability after surgical revascularization. Circulation 110(12):1535–1541PubMedCrossRefGoogle Scholar
  52. Shaw LJ, Berman DS (2009) Functional versus anatomic imaging in patients with suspected coronary artery disease. Cardiol Clin 27(4):597–604PubMedCrossRefGoogle Scholar
  53. Shaw LJ, Iskandrian AE (2004) Prognostic value of gated myocardial perfusion SPECT. J Nucl Cardiol 11(2):171–185PubMedCrossRefGoogle Scholar
  54. Shaw LJ et al (2008) 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 117(10):1283–1291PubMedCrossRefGoogle Scholar
  55. Taillefer R et al (1997) Comparative diagnostic accuracy of Tl-201 and Tc-99 m sestamibi SPECT imaging (perfusion and ECG-gated SPECT) in detecting coronary artery disease in women. J Am Coll Cardiol 29(1):69–77PubMedCrossRefGoogle Scholar
  56. Tonino PA et al (2009) Fractional flow reserve versus angiography for guiding percutaneous coronary intervention. N Engl J Med 360(3):213–224PubMedCrossRefGoogle Scholar
  57. Wijns W et al (1986) Effect of coronary occlusion during percutaneous transluminal angioplasty in humans on left ventricular chamber stiffness and regional diastolic pressure-radius relations. J Am Coll Cardiol 7(3):455–463PubMedCrossRefGoogle Scholar

Copyright information

© Springer-Verlag Berlin Heidelberg 2012

Authors and Affiliations

  1. 1.Department of Clinical RadiologyLudwig-Maximilians UniversityMunichGermany

Personalised recommendations