Additional value of adenosine-stress dynamic CT myocardial perfusion imaging in the reclassification of severity of coronary artery stenosis at coronary CT angiography
Introduction
Multidetector computed tomography (MDCT) has high sensitivity for the detection of coronary artery disease, with good negative predictive values.1, 2, 3, 4, 5 However, it is limited for evaluating the physiological significance of particular stenotic lesions. Currently, invasive techniques, such as fractional flow reserve (FFR), as well as non-invasive examinations, such as single photon-emission computed tomography (SPECT) and positron-emission tomography (PET) are used for this task. However, although PET is capable of quantitatively measuring myocardial blood flow (MBF) and coronary flow reserve, neither SPECT nor PET are able to provide anatomical assessment of coronary arteries. Invasive coronary angiography (ICA) with FFR provides information on the degree of arterial stenosis and its haemodynamic significance, not visualizing myocardial perfusion directly. Cardiac magnetic resonance imaging (MRI) is also used for myocardial perfusion imaging (MPI). However, cardiac MRI is expensive and time-consuming compared to cardiac CT. Furthermore, the number of sections in myocardial perfusion MRI is limited and dark-rim artefacts decrease its diagnostic accuracy.6
In most myocardial CT perfusion (CTP) research to date, a “snapshot” protocol has been used with the acquisition of a CTP dataset in a single phase both at rest and during stress.7, 8, 9, 10, 11, 12, 13 After the introduction of “shuttle mode” of 128-section dual-source CT (DSCT), adenosine-stress dynamic-stress myocardial perfusion CT (ASDCTP) and quantitative analysis of MBF14, 15, 16, 17, 18, 19, 20 have recently been adopted. The purpose of the present study was to evaluate the additional value of ASDCTP using a second-generation DSCT for the detection of significant coronary artery stenosis compared to coronary CT angiography (CCTA).
Section snippets
Subjects
This study included 34 consecutive patients (65 ± 11 years, 79% men) who underwent ASDCTP using a 128-section DSCT with subsequent ICA. They were referred to radiology department for the evaluation of clinically suspected CAD. All patients were examined with ICA within 3 months of the CTP examination (22 ± 18 days; range 0–75 days). In our institution, adenosine-induced CTP or MR perfusion have routinely replaced SPECT. Patients were screened for contraindications to adenosine administration.
Patient characteristics
Patient characteristics are listed in Table 1. Of the 34 patients (mean 65 ± 11 years old), 79% were men, 94% had a body mass index (BMI) below 30, 65% had experienced angina pectoris previously, 41% were former or current smokers, and 50% had diabetes mellitus. The pretest probability of coronary artery disease of those patients was classified as follows: low, 12 patients (35%); intermediate, 16 patients (47%); high, six patients (18%). In patients with low pretest probability of coronary
Discussion
In the present study, the diagnostic performances of CCTA for the detection of significant stenosis were compared at thresholds of 50% and 70% diameter stenosis before and after perfusion analysis, using ICA as the reference standard. After ASDCTP interpretation with a cut-off value of 50% luminal stenosis, the addition of ASDCTP showed significant improvement in diagnostic estimates on a vessel-based analysis after reclassification (p < 0.01). However, at a cut-off value of 70% stenosis,
Acknowledgement
The authors appreciate the contribution of Ms Sang Eun Lee for the illustration in Fig. 2.
This study was supported by a grant of Korea Health Technology R&D Project, Ministry for Health, Welfare & Family Affairs, Republic of Korea (A102065-26).
References (30)
- 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) - et al.
Diagnostic accuracy of 64-slice computed tomography coronary angiography: a prospective, multicenter, multivendor study
J Am Coll Cardiol
(2008) - et al.
Multidetector computed tomography myocardial perfusion imaging during adenosine stress
J Am Coll Cardiol
(2006) - et al.
Adenosine-induced stress myocardial perfusion imaging using dual-source cardiac computed tomography
J Am Coll Cardiol
(2009) - et al.
Adenosine-stress dynamic real-time myocardial perfusion CT and adenosine-stress first-pass dual-energy myocardial perfusion CT for the assessment of acute chest pain: initial results
Eur J Radiol
(2012) - et al.
Stress and rest dynamic myocardial perfusion imaging by evaluation of complete time–attenuation curves with dual-source CT
JACC Cardiovasc Imaging
(2010) - et al.
Incremental value of an integrated adenosine stress-rest MDCT perfusion protocol for detection of obstructive coronary artery disease
J Cardiovasc Comput Tomogr
(2011) - et al.
Cardiac CT: are we underestimating the dose? A radiation dose study utilizing the 2007 ICRP tissue weighting factors and a cardiac specific scan volume
Clin Radiol
(2010) - et al.
Quantification of obstructive and nonobstructive coronary lesions by 64-slice computed tomography: a comparative study with quantitative coronary angiography and intravascular ultrasound
J Am Coll Cardiol
(2005) - et al.
Diagnostic accuracy of 64-slice computed tomography coronary angiography in a large population of patients without revascularisation: registry data and review of multicentre trials
Radiol Med
(2010)
Italian multicenter, prospective study to evaluate the negative predictive value of 16- and 64-slice MDCT imaging in patients scheduled for coronary angiography (NIMISCAD-Non Invasive Multicenter Italian Study for Coronary Artery Disease)
Eur Radiol
Coronary CT angiography using 64 detector rows: methods and design of the multi-centre trial CORE-64
Eur Radiol
Diagnostic performance of myocardial perfusion MR at 3 T in patients with coronary artery disease
Radiology
Myocardial perfusion imaging using adenosine triphosphate stress multi-slice spiral computed tomography: alternative to stress myocardial perfusion scintigraphy
Circ J
Incremental value of adenosine-induced stress myocardial perfusion imaging with dual-source CT at cardiac CT angiography
Radiology
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