Comparison of Dual-Energy Computed Tomography of the Heart With Single Photon Emission Computed Tomography for Assessment of Coronary Artery Stenosis and of the Myocardial Blood Supply

doi:10.1016/j.amjcard.2009.03.051

The American Journal of Cardiology

Volume 104, Issue 3, 1 August 2009, Pages 318-326

https://doi.org/10.1016/j.amjcard.2009.03.051 Get rights and content

To evaluate the performance of dual-energy computed tomography (CT) for integrative imaging of the coronary artery morphology and the myocardial blood supply, 36 patients (15 women, mean age 57 ± 11 years) with equivocal or incongruous single photon emission CT (SPECT) results were investigated by a single-contrast medium-enhanced, retrospectively electrocardiographic-gated dual-energy CT (DECT) scan with simultaneous acquisition of high and low x-ray spectra. Thirteen patients subsequently underwent invasive coronary angiography (ICA). The DECT data were used to reconstruct anatomic coronary CT angiographic images and to map the myocardial iodine distribution within the left ventricular myocardium. Two independent observers analyzed all DECT studies for stenosis and myocardial iodine defects. A segmental comparison was performed between the stress/rest SPECT perfusion defects and DECT iodine defects and between the ICA and coronary CT angiographic findings for stenosis. The sensitivity, specificity, positive predictive value, negative predictive value, and accuracy were estimated, along with the κ statistics. Overall, DECT had 92% sensitivity and 93% specificity, with 93% accuracy for detecting any type of myocardial perfusion defect seen on SPECT. Contrast defects at DECT correctly identified 85 (96%) of 89 fixed and 60 (88%) of 68 reversible myocardial perfusion defects. The interobserver agreement was very good (weighted κ = 0.87). Compared with ICA, coronary CT angiography had 90% sensitivity, 94% specificity, and 93% accuracy for the detection of >50% stenosis. In conclusion, our initial experience suggests that DECT, as a single examination, might be promising for the integrative analysis of the coronary artery morphology and the myocardial blood supply and is in good agreement with ICA and SPECT.

Section snippets

Methods

Our human research committee approved the present retrospective analysis and waived the need for informed patient consent. The data from 36 consecutive patients who had undergone rest/stress SPECT myocardial perfusion imaging followed by DECT were retrospectively analyzed. All patients had been clinically referred for coronary CT angiography (cCTA) to further evaluate the SPECT results in the context of known or suspected coronary artery disease. Nine patients were referred for cCTA for

Results

The population consisted of 36 patients, 21 of whom were men (67%), with an average age of 57 ± 11 years and an average body weight of 85 ± 19 kg. Nine patients had known coronary artery disease after revascularization, and 27 did not have any medical history of coronary artery disease. Of these 27 patients, 6 (22%) had a low, 17 (63%) had an intermediate, and 4 (15%) had a high estimated pretest probability for obstructive coronary artery disease using the Duke clinical score. The average

Discussion

The clinical pathways for treating patients with suspected coronary artery disease who have clearly negative or clearly positive results on physiologic testing (e.g., ergometric stress testing, myocardial perfusion imaging, stress echocardiography) that are congruous with the patient's clinical presentation are well established.10, 11 Diagnostic dilemmas arise when the findings from physiologic testing are equivocal or incongruous with the patient's overall clinical presentation. Currently, in

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Patients who underwent rest-stress DECT on a 2nd generation dual-source system and cardiac magnetic resonance (CMR) were retrospectively included from a prospective study cohort. CMR was performed to identify ischemic and infarcted myocardium and categorize patients into ischemic, infarcted, and control groups. Controls were analyzed on a per-slice and per-segment basis. Regions of interest (ROIs) were placed in ischemic and infarcted areas based on CMR. Additionally, ROIs were placed in the septal area to assess normal and remote myocardium.
We included 42 patients: 10 ischemic, 17 infarcted, and 15 controls. Iodine concentrations showed no significant between segments in controls. Iodine concentrations for normal myocardium increased significantly from rest to stress (median 3.7 mg/mL (interquartile range 3.5–3.9) vs. 4.5 mg/mL (4.3–4.9)) (p < 0.001). Iodine concentrations in diseased myocardium were significantly lower than in normal myocardium; 1.3 mg/mL (0.9–1.8) and 0.6 mg/mL (0.4–0.8) at rest and stress in ischemic myocardium, and 0.3 mg/mL (0.3–0.5) and 0.5 mg/mL (0.5–0.7) at rest and stress in infarcted myocardium (p < 0.005 and p < 0.001). At rest only, iodine concentrations were significantly lower in infarcted vs. ischemic myocardium (p < 0.001). The optimal threshold for differentiating diseased from normal myocardium was 2.5 mg/mL and 2.1 mg/mL for rest and stress (AUC 1.00). To discriminate ischemic from infarcted myocardium, the optimal threshold was 1.0 mg/ml (AUC 0.944) at rest.
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: Dr. Schoepf is a medical consultant for Bayer-Schering, Wayne, New Jersey, Bracco, Princeton, New Jersey, General Electric, Princeton, New Jersey, Medrad, Indianola, Pennsylvania, Siemens, Malvern, Pennsylvania, and TeraRecon, San Mateo, California and receives research support from Bayer-Schering, Bracco, General Electric, Medrad, and Siemens; Dr. Costello is a medical consultant for Bracco and receives research support from Siemens; and Dr. Zwerner receives research support from Boehringer-Ingelheim, Bristol Myers Squib, Bracco, and Siemens.

: This work was supported in part by the Hounsfield Award of the Society of Computed Body Tomography and Magnetic Resonance (SCBT-MR).

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Coronary artery diseaseComparison of Dual-Energy Computed Tomography of the Heart With Single Photon Emission Computed Tomography for Assessment of Coronary Artery Stenosis and of the Myocardial Blood Supply

Section snippets

Methods

Results

Discussion

Am J Cardiol

Eur J Radiol

J Am Coll Cardiol

J Am Coll Cardiol

J Am Coll Cardiol

Chest

First performance evaluation of a dual-source CT (DSCT) system

Eur Radiol

Diagnostic accuracy of dual-source multi-slice CT-coronary angiography in patients with an intermediate pretest likelihood for coronary artery disease

Eur Heart J

Images in cardiovascular medicine: myocardial ischemia diagnosed by dual-energy computed tomography: correlation with single-photon emission computed tomography

Circulation

Dual-energy CT of the heart for diagnosing coronary artery stenosis and myocardial ischemia-initial experience

Eur Radiol

Material differentiation by dual energy CT: initial experience

Eur Radiol

Radiation dose to patients from cardiac diagnostic imaging

Circulation

Selective iodine imaging using K-edge energies in computerized x-ray tomography

Med Phys

Exercise myocardial perfusion SPECT in patients without known coronary artery disease: incremental prognostic value and use in risk stratification

Circulation

Circulation

Coronary artery disease
Comparison of Dual-Energy Computed Tomography of the Heart With Single Photon Emission Computed Tomography for Assessment of Coronary Artery Stenosis and of the Myocardial Blood Supply