Myocardial perfusion imaging versus CT coronary angiography: when to use which?

Both anatomy- and physiology-based approaches to patient management have advantages and limitations. Compared with the latter, the former has a superior ability to exclude disease and does not miss high-risk coronary artery disease (CAD). However, it is limited by a possibility of overestimating the severity of CAD and of potentially failing to determine which posttest therapeutic approach optimizes treatment benefit. On the other hand, although a physiology-based approach could potentially identify optimal therapeutic strategies, the possibility of both false-positive and false-negative findings is a concern. This review incorporates some of the more recent advances in CT coronary angiography and myocardial perfusion imaging (MPI), including PET MPI, into a discussion of anatomic versus physiologic imaging and provides our perspective on how an anatomy-based testing strategy centered in CT coronary angiography versus a physiology-based testing strategy with MPI may be clinically used for the evaluation of known or suspected CAD in symptomatic patients.