Original ArticleDirect comparison of rest and adenosine stress myocardial perfusion CT with rest and stress SPECT
Introduction
Single photon emission computed tomography myocardial perfusion imaging (SPECT-MPI) is a widely utilized and extensively validated method for assessing myocardial perfusion. A significant body of data demonstrates the high diagnostic accuracy of MPI for the detection of myocardial ischemia and scar, and the determination of myocardial viability, as well as the prognostic value of MPI in predicting long-term cardiovascular outcomes.1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11
Rest myocardial computed tomography (CT) perfusion imaging has demonstrated good correlation with resting perfusion magnetic resonance imaging and histopathology for the detection of perfusion abnormalities in both human and animal studies.12, 13, 14, 15, 16 These results suggest that iodinated CT contrast medium has similar pharmacokinetics to gadolinium MRI contrast agents and demonstrates rapid early enhancement in healthy myocardium, relatively slow enhancement in ischemic territories, and markedly delayed washout in infarcted territories.17 These differential kinetics suggested the possibility of discriminating normal from abnormal myocardium, as well as differentiation of scar from ischemic myocardium.
Emerging animal and human data demonstrate good correlation of stress myocardial CT perfusion imaging with measurements of myocardial blood flow as defined by radionuclide microspheres and good diagnostic accuracy for the detection of obstructive coronary artery disease by comparison with invasive angiography.18, 19, 20, 21 Our group has recently described a novel technique for assessing myocardial perfusion in humans using adenosine-mediated stress imaging (CTP) with dual source computed tomography (DSCT) that offers submillimeter spatial resolution and tomographic datasets.22,23
However, comparison of a physiologic test with an anatomic gold standard is not ideal. The angiographic percent luminal narrowing of a stenosis does not always determine its hemodynamic significance. Furthermore, the physiologic effects of the number, shape, length, and location of coronary lesions can impact the hemodynamic significance of disease. Finally, patients with syndrome X or microvascular disease may have ischemia in the absence of angiographic abnormalities.
Thus, the aim of this study was to determine the level of agreement for presence and extent of perfusion abnormalities at stress and rest between CTP and MPI on a per-segment, per-vessel, and per-patient basis.
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Patient Population
Eligible participants for the study included 955 consecutive patients in our institution with age ≥ 40 years who underwent a nuclear stress test. Two populations were screened for eligibility: (1) all patients scheduled to undergo clinically indicated invasive angiography who have had a prior nuclear MPI within the previous 3 months; and (2) all patients who underwent nuclear MPI and were found to have high-risk features (i.e., high likelihood to be referred for invasive angiography). Exclusion
Patient Population
Table 1 summarizes baseline patient characteristics. Among the 47 study participants, the average age was 62.4 ± 10.2 years, 80.9% were male, 23.4% had diabetes 87.2% had hypertension, and 87.2% had dyslipidemia. The prevalence of obesity was 41.2% and the average BMI was 31.0 ± 5.6 kg/m2. The prevalence of prior angina, myocardial infarction, and revascularization was 57.4%, 36.2% and 38.3%, respectively. Implantable cardioverter defibrillator (ICD) was the only cardiac device represented in
Discussion
In this direct comparison of two modalities of stress and rest MPI in patients, we demonstrated an excellent correlation between CTP and SPECT for the detection of perfusion abnormalities and for the assessment of defect severity on a per-segment, per-vessel, and per-patient basis.
Myocardial perfusion imaging with 201-Tl and 99m-Tc MIBI during exercise or pharmacologic stress enables the noninvasive detection of perfusion defects and can provide indirect assessment of coronary anatomy with a
Conclusions
SPECT is the mostly widely utilized technique for assessing myocardial perfusion. The current study validates the ability of CTP to assess myocardial perfusion at rest and during adenosine, when compared directly to SPECT. Thus, with a single study and with no increase in radiation, one can assess myocardial perfusion and coronary anatomy simultaneously.
We conclude that adenosine-mediated stress MPI with DSCT compares well with nuclear stress testing in a direct correlation of segments,
Acknowledgments
The authors would like to thank the CT technologists, the Radiology department nursing staff, and the staff physicians in the Division of Cardiology at the Massachusetts General Hospital.
Funding sources
This study is supported in part by a grant from Astellas Pharma, Inc. Drs Blankstein, Ghoshhajra, Shturman, and Rogers have received support from NIH grant 1T32 HL076136. Dr Ghoshhajra has received support from RSNA 213740. Dr Cury reports receiving research grant support from Astellas, Pharma, Inc.
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