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Computed tomography stress myocardial perfusion imaging in patients considered for revascularization: a comparison
Brian S Ko1, James D Cameron, Ian T Meredith
1Monash Cardiovascular Research Centre, Monash Heart, Southern Health, 246 Clayton Road, Clayton, 3168 VIC, Australia.
Insights
Adenosine stress computed tomography myocardial perfusion imaging (CTP) shows moderate accuracy for detecting myocardial ischemia compared to fractional flow reserve (FFR). Combining CTP with computed tomography coronary angiography (CTA) significantly improves diagnostic accuracy for ischemia.
Area of Science:
- Cardiovascular imaging
- Non-invasive diagnostic techniques
- Myocardial perfusion assessment
Background:
- Adenosine stress computed tomography myocardial perfusion imaging (CTP) is an emerging non-invasive method for detecting myocardial ischemia.
- The diagnostic value of CTP compared to fractional flow reserve (FFR), a gold standard for ischemia assessment, is not well-established.
Purpose of the Study:
- To determine the diagnostic accuracy of CTP for detecting myocardial ischemia.
- To evaluate the incremental value of combining CTP with computed tomography coronary angiography (CTA) compared to FFR.
Main Methods:
- Forty-two patients with significant coronary stenosis underwent FFR and CT assessment, including CTP, delayed contrast enhancement scan, and CTA using 320-detector row CT.
- Fractional flow reserve (FFR) was determined in 86 vessel territories, with FFR ≤0.8 indicating significant ischemia.
Main Results:
- CTP correctly identified 76% of ischemic and 84% of non-ischemic territories, with per-territory sensitivity and specificity of 76% and 84%, respectively.
- The combination of CTA (≥50% stenosis) and CTP (perfusion defect) achieved 98% specificity for ischemia detection.
- Concordant CTA/CTP results demonstrated high accuracy in detecting and excluding ischemia, with acceptable radiation exposure (mean 11.3 mSv for combined CT).
Conclusions:
- CTP is moderately accurate in identifying perfusion defects associated with ischemia, as assessed by FFR.
- The combination of CTA and CTP offers high accuracy for ischemia detection and exclusion when results are concordant.
- This combined approach is feasible with acceptable radiation doses using advanced CT technology.
Aims:
Adenosine stress computed tomography myocardial perfusion imaging (CTP) is an emerging non-invasive method for detecting myocardial ischaemia. Its value when compared with fractional flow reserve (FFR), a highly accurate index of ischaemia, is unknown. Our aim was to determine the diagnostic accuracy of CTP and its incremental value when used with computed tomography coronary angiography (CTA) for detecting ischaemia compared with FFR.
Methods And Results:
Forty-two patients (126 vessel territories), who had at least one ≥50% angiographic stenosis on invasive angiography considered for non-urgent revascularization, were included and underwent FFR and CT assessment, including CTP, delayed contrast enhancement scan and CTA all acquired using 320-detector row CT, and prospective ECG gating. Fractional flow reserve was determined in 86 territories subtended by vessels with ≥50% stenosis upon visual assessment. Fractional flow reserve ≤0.8 was considered to indicate significant ischaemia. Computed tomography myocardial perfusion imaging correctly identified 31/41 (76%) ischaemic territories and 38/45 (84%) non-ischaemic territories. Per-vessel territory sensitivity, specificity, positive, and negative predictive values of CTP were 76, 84, 82, and 79%, respectively. The combination of a ≥50% stenosis on CTA and perfusion defect on CTP was 98% specific for ischaemia, while the presence of <50% stenosis on CTA and normal perfusion on CTP was 100% specific for exclusion of ischaemia. Mean radiation for CTP and combined CT was 5.3 and 11.3 mSv, respectively.
Conclusion:
Computed tomography myocardial perfusion imaging is moderately accurate in identifying perfusion defects associated with ischaemia as assessed by FFR in patients considered for revascularization. In territories, where CTA and CTP are concordant, CTA/CTP is highly accurate in the detection and exclusion of ischaemia. This is achievable with acceptable radiation exposure using 320-detector row CT and prospective ECG gating.
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