Adenosine stress myocardial perfusion imaging and dual-source computed tomography for detecting coronary heart disease
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Objective To explore the value of adenosine(ADE) stress gated myocardial perfusion imaging(G-MPI) and dual-source CT coronary angiography(DSCTCA) in diagnosis of coronary artery disease(CAD).Methods Fifty-three patients with low,medium and high probability of CAD underwent resting(REST),ADE stress G-MPI and DSCTCA,then they underwent CAG within 4 weeks.MPI results were analyzed using the American Heart Association 17 segment 5-point scale(0—4 points) visual semi-quantitative method,and the resting and stress rating of the difference 1 were identified as reversible defect.Coronary stenosis were determined using international common law of DSCTCA visual diameter and were divided into normal and stenosis 50% or ≥50%.Taking CAG results as gold standards and stenosis ≥50% defined as CAD,diagnostic value of MPI and DSCTCA was compared.Results According to CAG results,the sensitivity,specificity and accuracy of G-MPI and DSCTCA in diagnosis of CAD was 94.44%(34/36),52.94%(9/17),81.13%(43/53) and 88.89%(32/36),88.24%(15/17),88.68%(47/53),respectively(χ2=9.28,P=0.005).Conclusion G-MPI and DSCTCA both have high value in diagnosis of CAD,combination of these two methods can improve the diagnostic utility of CAD through obtaining both functional and anatomical information.Keywords:
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To determine the accuracy of dual-source CT (DSCT) coronary angiography (CAG) for the diagnosis of coronary artery disease (CAD) that induces perfusion defects at myocardial perfusion imaging (MPI) with single photon emission computed tomography (SPECT), by using SPECT and conventional CAG as the reference standard.Thirty-five patients with suspected or known CAD underwent both DSCT coronary angiography and MPI (using exercise or adenosine stress-rest protocol) with technetium-99m sestamibi SPECT. All the patients were beta-blockers-naïve before DSCT scan. The DSCT CAG studies were classified as having no stenosis, non-obstructive (< 50% luminal narrowing) stenosis, or obstructive (> or = 50% luminal narrowing) stenosis. MPI examinations were classified as showing normal or abnormal (reversible and/or fixed defects). A comparative regional analysis of coronary stenosis on DSCT versus myocardial perfusion on SPECT was made. In a subset of 20 patients, CAG was performed as a reference standard for CT angiography.On the basis of the DSCT data, 98.4% of coronary segments were assessable. Twenty-seven branches were classified as having no stenosis, among which 85% had normal MPI. Nine branches showed non-obstructive stenosis and 69 branches showed at least one obstructive lesion. Only 50 (64%) branches with an abnormal DSCT had abnormal MPI; even in branches with obstructive stenosis on DSCT, 23 (33%) still had a normal MPI. By receiver operating characteristic curve analysis, at the optimal cutoff value of 58% stenosis, the sensitivity and specificity of DSCT to detect myocardial perfusion defect as defined by SPECT were 85% and 65%. In the subgroup compared with CAG, the sensitivity and specificity of DSCT to identify obstructive stenosis were 93% and 96%.DSCT and SPECT provide mutually complementary information on CAD. CT angiography can help rule out functionally relevant CAD, but has poor capability in predicting ischemia. DSCT provides high-quality diagnostic image without heartbeat controlling and has a high accuracy in detecting obstructive stenosis.
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Objective To investigate myocardial perfusion imaging(MPI) combined with coronary CT angiography(CTA) in diagnosis of culprit coronary artery.Methods From 2012 Februarv-2013 December,hospitalized patients with coronary heart disease(33 cases) were enrolled,male of 25 cases,female ol 8 cases,age from 35 to 75 years old(55.2 ±20.2),they were underwent N-NH,PET adenosine/ resting MPI and coronary artery CTA examination,within 1 months of coronary arteriography(CAG),respectively.The MPI,CTA and CAG were analyzed;using CAG as golden standard,the diagnostic value of coronary CTA,MPI and MPI combined coronary artery CTA were analyzed.Results(1) The sensitivity of CTA in diagnosis of coronary heart disease was 90.0%(36/40),the specificity was 95.0%(302/318),the predictive value was 69.2%(36/52),the predictive value was 98.7%(302/306).(2) The sensitivity of MPI in diagnosis of coronary heart disease was 90.9%(20/22),the specificity was 90.9%(10/11),the predictive value was95.2%(20/21),the predictive value was 83.3%(10/12).(3) The sensitivity of MPI combined with CTA in diagnosis ol coronary heart disease was 95.5%(20/21),the specificity was 100%(11/11),the predictive value was100%(21/21),the predictive value was 91.7%(11/12).Conclusion MPI combined with coronary CTA can decrease the false positive and false negative results caused by MPI or CTA alone,provides higher accuracy for the diagnosis and treatment of coronary heart disease,especially to improve the detection rate of culprit vessel.
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Objective
To evaluate the diagnostic value of one-stop cardiac CT (stress dynamic CT-MPI combining with CTA) in CAD.
Methods
Thirty patients underwent CCTA combined with stress dynamic CT-MPI and stress SPECT-MPI including 16 patients underwent ICA were retrospectively enrolled. All procedures were performed within 2 weeks without related treatment. CT-MPI and SPECT-MPI were evaluated visually and MBF was quantified according to dynamic CT-MPI which was compared through paired t test. The diagnostic value of CT-MPI for myocardial ischemia was evaluated with SPECT-MPI as the reference standard. The consistency between the two techniques was determined by Kappa test. With SPECT combined with ICA as the reference standard, we evaluated the value of CT-MPI and its combination with CCTA in the diagnosis of CAD with hemodynamic stenosis.
Results
On stress CT-MPI, 19 of 30 patients and 52 segments were evaluated with myocardial perfusion defects. There was a significant difference in MBF values between normal[(117.61±29.82)ml·100 ml-1·min-1] and hypoperfused [(80.60±22.15)ml·100 ml-1·min-1] segments (t=15.764,P<0.001). With SPECT as reference standard, the sensitivity, specificity were 94.12% (32/34), 95.80% (456/476) on the vessel basis. The Kappa value of the two examinations was 0.772(P<0.001). As for the 16 patients who also underwent ICA, 15 patients with 22 vessel-areas had hemodynamic stenosis on CT-MPI. Compared with SPECT combined with ICA, the sensitivity, specificity for detecting hemodynamic stenosis were 92.31% (12/13), 71.43% (25/35) for CT-MPI; 100% (13/13), 51.43% (18/35) for CTA and 92.31% (12/13), 82.86% (29/35) for CT-MPI combined with CTA, respectively. Moderate correlation was observed between the combination of CT-MPI and CCTA and reference standard (r=0.690, P<0.001).
Conclusion
Stress dynamic CT-MPI can detect myocardial perfusion defects and hemodynamic changes and improves the diagnostic ability of functional stenosis of CAD combined with CTA, which can finally achieve the one-stop mode of cardiac CT in CAD.
Key words:
Myocardial ischemia; Tomography, X-ray computed; Myocardial perfusion imaging; Coronary stenosis
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Coronary heart disease is the most common cause of death in the general population. Multi detector Computed Tomography (MDCT) is noninvasive technique and can study the entire coronary-artery tree during a single imaging session. The aims of this study were to characterize coronary arteries in patients who were clinically diagnosed to have coronary artery disease (CAD) using (MDCT) 256 slices, and to compare the findings with other cardiac examinations outcome. The study was done at King Fahad Specialist Hospital-Alqaseem- KSA during the period from January to May 2013 .A total of 102 patients, 63(61.76%) males, and 39 (38.24 %) females were included. All patients with pre-test probability of CAD underwent coronary CT angiography with beta-blockers were administered prior to the scan, and other cardiac investigations were obtained. Patient’s age, gender, BMI, weight, Cholesterol level, Hypertension, Diabetes Mellitus, chest pain types, Calcium scoring, were evaluated and correlated with the CT findings and other cardiac investigation results. The evaluated arteries were Left Main Artery (LMA), Left Anterior Descending artery (LAD), Right Coronary Artery (RCA), and Left Circumference Artery (LCA) and were observed for plaques characterization, occlusion or stenosis. A significant association was detected between the CT plaques morphology and BMI, Hyper tension and calcium score at P-value < 0.05. Patients with normal findings in ECG 53 (57.6%) , Echocardiography 58.0(76.3%) and Myocardial Perfusion Imaging (MPI) 2(25.0%) were found to have positive cardiac disease in CTA. Echocardiography is able to characterize Atrial filibration, Heart failure, Ventricle diseases, Valve stenoses and has significant association with gender P-value 0.022 and BMI P-value 0.042.Myocardial Perfusion Imaging results showed the cardiac function and ejection fraction. No significant association was found between CT findings in coronary arteries and MPI results at P-value 0.789.Coronary CTA disclose diseases in arteries (98.5%), heart anomalies or valve disease 3(3%) ,plaques with significant stenosis 4(4%) , plaque without significant stenosis 11(10.9%) ,stenosis without plaques 14 (14%) and total occlusion 1(1%). In relation to other cardiac tests; cardiac ischemic changes can be detected in ECG, MPI and Echocardiography. Association between CT Plaque Characteristics and Invasive Coronary Arteries results were significant for LAD and RCA at P-value 0.05. Coronary CTA is a promising non-invasive technique and is highly recommended for characterization of Coronary Arteries and diagnosis the CAD; it could be of great value prior to invasive coronary angiography, although ECG, Echocardiography and MPI(SPECT) are better in studying function.
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Objective To evaluate the diagnostic accuracy of a combined non-invasive assessment of coronary artery disease with coronary computed tomography angiography(CCTA) and myocardial perfusion imaging(MPI) for the detection of flow-limiting coronary stenoses and its potential as a gatekeeper for invasive examination and treatment.Methods A total of 78 patients with known or suspected coronary artery disease(CAD) were examined by adenosine stress/rest MPI and coronary angiography(CAG) within one month,at the same time these patients underwent CCTA with the same SPECT/CT facility.MPI was evaluated by semi-quantitative visual interpretation using a 15-segment model.According to CAG and CCTA standard,a significant stenosis was defined as a diameter reduction of ≥50%.Detection of flow-limiting stenoses(justifying revascularization) by the combination of CCTA and MPI(MPI/CCTA) was compared with the combination of CAG plus MPI(MPI/CAG),which served as standard of reference.Results In 78 patients,MPI image revealed 66 reversible,6 fixed and 6 normal.The distribution of the perfusion defects among the different coronary artery territories was as follows: reversible perfusion defects: left anterior descending artery(LAD)(n=55),left circumflex artery(LCX)(n=14),right coronary artery(RCA)(n=11);fixed perfusion defects: LAD(n=4);RCA(n=3).CCTA image analysis revealed a stenosis in 74/234 coronary arteries of 56/78 patients.MPI/CCTA image analysis revealed a stenosis in 56/78 patients.The diagnostic sensitivity,specificity,accuracy,positive and negative predictive values by MPI/CCTA vs MPI/CAG for the detection of flow-limiting coronary stenosis on patient-based and vessel-based analysis were 94.33%,72.00%,87.18%,87.71%,85.71% and 88.71%,92.44%,91.45%,80.89%,95.78%.All of revascularization procedures(46,100%) were associated with ischemia on MPI,but more than a third(25/67,37%)of revascularized vessels were not associated with ischemia on MPI.Conclusion The combined non-invasive approach MPI/CCTA has an excellent acuracy to detect flow-limiting coronary stenoses compared with MPI/CAG.Its advantage lies in the non-invasive evaluation of coronary anatomy and function,and its use as a gatekeeper appears to make a substantial part of revascularization procedures redundant.
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Myocardial perfusion imaging (MPI) is an accurate noninvasive test for patients with suspected obstructive coronary artery disease (CAD) and coronary artery calcium (CAC) score is known to be a powerful predictor of cardiovascular events. Collection of CAC scores simultaneously with MPI is unexplored.We aimed to investigate whether automatically derived CAC scores during myocardial perfusion imaging would further improve the diagnostic accuracy of MPI to detect obstructive CAD.We analyzed 150 consecutive patients without a history of coronary revascularization with suspected obstructive CAD who were referred for 82Rb PET/CT and available coronary angiographic data. Myocardial perfusion was evaluated both semi quantitatively as well as quantitatively according to the European guidelines. CAC scores were automatically derived from the low-dose attenuation correction CT scans using previously developed software based on deep learning. Obstructive CAD was defined as stenosis >70% (or >50% in the left main coronary artery) and/or fractional flow reserve (FFR) ≤0.80.In total 58% of patients had obstructive CAD of which seventy-four percent were male. Addition of CAC scores to MPI and clinical predictors significantly improved the diagnostic accuracy of MPI to detect obstructive CAD. The area under the curve (AUC) increased from 0.87 to 0.91 (p: 0.025). Sensitivity and specificity analysis showed an incremental decrease in false negative tests with our MPI + CAC approach (n = 14 to n = 4), as a consequence an increase in false positive tests was seen (n = 11 to n = 28).CAC scores collected simultaneously with MPI improve the detection of obstructive coronary artery disease in patients without a history of coronary revascularization.
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Objective To investigate the diagnostic efficiency of 64-slice CT coronary angiography(CTCA)to myocardial ischemia of coronary stenosis.Methods 99mTc-MIBI myocardial perfusion imaging(MPI)and 64-slice CTCA were performed in 30 patients with myocardial ischemia of coronary stenosis.Three coronary arteries were divided in to 12 segments in each patient,the diagnostic efficiency of CTCA to myocardial ischemia of coronary stenosis were eveluated taking MPI as diagnostic standard,and stenoses ≥50% and ≥75% as the cutoff value.Results In 9 patients,perfusion defected were found(6 reversible,3 fixed)on MPI.A total of 327 coronary arteries' segments were analyzed,quantitative CTCA revealed stenoses ≥50% in 25 segments(7.65%)and stenoses ≥75% in 12 segments(3.67%).When the cut-off was ≥50%,the sensitivity,specificity,negative and positive predictive value(NPV,PPV)and accuracy of CTCA by the abnormal images of MPI as diagnostic standard to observe abnormal arteries was 68.42%,96.14%,99.01%,52.00% and 95.41%,respectively;and 66.67%,99.04%,98.73%,66.67% and 97.55%,respectively,when cut-off at ≥75%.Taking abnormal MPI as diagnostic standard to observe the patients,the sensitivity,specificity,NPV,PPV and accuracy of CTCA was 66.67%,57.14%,80.00%,40.00% and 60.00% respectively,with the cut-off at ≥50%;and was 55.56%,85.71%,81.82%,62.50% and 76.67%,respectively,with the cut-off at ≥75%.Conclusion Sixty-four-slice CTCA is a reliable tool to rule out functionally relevant myocardial ischemia of coronary artery disease.However,further examination is necessory for patients with abnormal CTCA.
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Objective:To compare the effect of single myocardial perfusion imaging(MPI) and MPI combined with coronary CT angiography(CCTA) on coronary artery lesion diagnosis in patients of type 2 diabetes mellitus(DM) with coronary artery lesions. Methods:A total of 85 diabetic patients with coronary artery disease(CAD) or suspected CAD were examined by adenosine stress/rest MPI and coronary angiography(CAG) within one month,38 of them underwent CCTA with the same SPECT/CT facility.MPI was evaluated by semi quantitative visual interpretation using a 17-segment model.According to CAG and CCTA stan-dard,the coronary condition was defined as normal,mild,intermediate and severe lesions.CAG and CAG/ MPI combination were used to evaluate the effect of coronary lesion diagnosis for MPI and MPI/CCTA fusion imaging.Results:In 85 patients,MPI presented normal/abnormal was 22/63.MPI diagnostic sensitivity,specificity,accuracy,positive and negative prediction rate for coronary lesions were 80.19%,88.59%,85.10%,83.33% and 86.27% respectively;it showed 20(24%) mild lesion cases,12(14%) intermediate lesion cases and 31(36%) severe lesion cases.For 38 patients who underwent CCTA,the diagnostic sensitivity,specificity,accuracy,positive and negative prediction rate by MPI vs.MPI/CCTA were 74.55% vs.96.97%,81.36% vs.91.67%,78.07% vs.94.74%,78.85% vs.94.12% and 77.42% vs.95.65% respectively.MPI/CCTA fusion imaging presented normal 40.35%(46 segment /114 branch),intermediate or more stenosis 59.65%(68 segment /114 branch).Conclusion:MPI/CCTA fusion imaging has been superior to MPI alone for early CAD diagnosis in DM patients with coronary artery lesions.
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Hybrid PET myocardial perfusion imaging (MPI) with CT allows the incorporation of coronary artery calcium (CAC) into the clinical protocol. We aimed to determine whether the combined analysis of MPI and CAC could improve the diagnostic accuracy of PET MPI in detection of obstructive coronary artery disease (CAD).Consecutive patients (n = 152; mean age ± SD, 69 ± 12 y) without prior CAD, referred to (82)Rb PET MPI followed by invasive coronary angiography performed within 14 days, were studied. Myocardial perfusion was quantified automatically for left anterior descending, left circumflex, and right coronary artery territories as an ischemic total perfusion deficit (ITPD) for 456 vessels. Global and per-vessel CAC Agatston scores were calculated. Obstructive CAD was defined as 50% or greater stenosis of the left main and 70% or greater stenosis in the left anterior descending, left circumflex, and right coronary arteries. Logistic regression and 10-fold cross validation were used to derive and validate the combined ITPD/logCAC (logarithm of coronary calcium) scores.In the prediction of per-vessel obstructive CAD, the receiver-operating-characteristic area under the curve for combined per-vessel ITPD/logCAC score was higher, 0.85 (95% confidence interval [CI], 0.81-0.89), than standalone ITPD area under the curve, 0.81 (95% CI: 0.76-0.85), and logCAC score, 0.73 (95% CI, 0.68-0.78; P < 0.05). The integrated discrimination improvement of combined per-vessel ITPD/logCAC analysis was 0.07 (95% CI, 0.04-0.09; P < 0.0001), as compared with ITPD alone.Combined automatically derived per-vessel ITPD and logCAC score improves accuracy of (82)Rb PET MPI for detection of obstructive CAD.
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