[Cardiac imaging in suspected coronary artery disease]

Within the scope of this review, non-invasive imaging modalities applicable for further work-up of suspected coronary artery disease (CAD) are discussed with regard to methodology, diagnostic accuracy and prognostic value. All of these imaging modalities can be employed in patients with an intermediate pretest probability of disease, if ECG stress testing is either not reasonable, not possible due to physical limitations or if the result is inconclusive. Stress echocardiography is a cost-effective and an easily practicable method based on the indirect detection of myocardial ischemia by visually assessing provoked wall motion abnormalities. Therefore, its diagnostic value is mainly determined by individual expertise. In case of myocardial scintigraphy, reduced myocardial perfusion causes signal intensity differences in SPECT images following physical or pharmacological stress which are reversible at rest. Myocardial scintigraphy is characterised by a high negative predictive value at the expense of a lower specificity due to false positive results based on methodological limitations. Cardiovascular magnetic resonance imaging (CMR) offers a comprehensive cardiac study in a single procedure. Apart from detecting myocardial ischemia by dobutamine-stress-CMR or adenosine-perfusion-CMR, it enables the precise detection of even small areas of myocardial infarction on contrast-enhanced images. In spite of fascinating high-resolution coronary images, multi-detector computed tomography (MDCT) has hardly been included in current guidelines due to the unavoidable risks of radiation and contrast medium exposure and the current uncertainty in defining appropriate clinical indications. However, quantification of coronary calcium is easily performed and may be useful for prognostic assessment in patients with intermediate risk profile.