Computed Tomographic Angiography and Nuclear Myocardial Perfusion

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The cost and the risk of invasive angiography have encouraged the development of new diagnostic methods that allow the coronary arteries to be visualized non-invasively. The last decade has seen great strides in the field of cardiac imaging, particularly in the ability of cardiac computed tomographic angiography (CTA) to visualize the coronary lumen with excellent diagnostic accuracy (see Table 1)1-2. Three papers with 64-row multi-detector CT (MDCT) demonstrate a sensitivity of 94% and specificity of 93%.1-2,29 This suggests that CTA can serve as an effective gate-keeper to aid a strategy of selective cardiac catheterization(see Figure 1). Being such a modality, CTA is now being increasingly used in clinical practice. As a result of having high spatial and improved temporal resolution, this imaging modality not only allows branches of the coronary artery to be evaluated but also allows simultaneous analysis of other cardiac structures, making it extremely useful for other cardiac applications.3-4 Moreover, coronary artery calcium (CAC) detected by computed tomography has been shown to be highly specific for atherosclerosis and has prognostic value, yielding valuable information for risk stratification, being both incremental and independent to traditional risk factors.5-9 The combination of CAC and CTA allows for accurate risk stratification to choose lipid-lowering targets.10 Other uses of CTA include calculation of ejection fraction, as well as assessment of global and regional wall motion evaluation.11


Myocardial perfusion imaging (MPI) is an established method for non-invasively assessing the functional significance of coronary stenoses and delivers valuable information for risk stratification. Patients with stable angina and normal MPI results have a low risk of death or fatal myocardial infarction (MI) and therefore no intervention is required for these patients.12-16 Even in patients with documented CAD, normal MPI results have been shown to have similar low event rates.17-18 MPI identifies myocardial perfusion defects, analyzing the functional relevance of coronary artery stenoses, and provides important informatio for clinical decision making.12 However, MPI performs less well in the setting of cardiomyopathy or left bundle branch block, and does not allow for the assessment of subclinical atherosclerosis, so treating physicians do not develop an accurate target of lipid-lowering therapy after a negative test. A negative test implies to many physicians and patients the presence of normal coronary arteries, but extensive subclinical atherosclerosis may also be present.

Figure 1: Selective Cardiac Catheterization
Panel A: A CT angiogram demonstrating a subtotal stenosis of the ostium of the left anterior descending artery. This prompted cardiac catheterization (Panels B and C), which demonstrated the same lesion on invasive angiography.The patient ultimately went on to stenting of that lesion./>/>


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