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Chest Pain Evaluation: Complimentary Role of
Cardiac CT and MR
Minh Nguyen MD, Christopher Klassen MD, PhD,
Kiran Kareti, MD, Birgit Stolze,
Alan Siuciak, Norbert Wilke, MD
University of Florida, Jacksonville, Health Science
Center, Department of Radiology and
Cardiovascular Center
Corresponding Author:
Norbert Wilke, MD
Associate Professor of Radiology
Associate Professor of Medicine
Chief, Cardiovascular MR and CT
University of Florida
Health Science Center
655 West Eighth Street
Jacksonville, FL, 32209-6511
Call: 904-244-8723
Page: 904-306-4256
Fax: 904-244-3382
Introduction
C
oronary artery disease (CAD) continues to invasive imaging plays a much less important role
be one of the leading causes of death in the in these patients. Since cardiac catheterization does
United States. Each year, approximately 8 carry a small morbidity (1-2%) and mortality risk
million patients are seen in the emergency room for (0.1%), alternative noninvasive modalities to iden-
chest pain. About 25% have acute MI or unstable an- tify the low risk patients to exclude them from the
gina, 25% have stable angina, and up to 50% have costs and risks of cardiac catheterization is desirable.
non-cardiac chest pain. The cost is over $3 billion Noninvasive modalities are also needed to assess the
for those without acute diseases. Unfortunately, at intermediate risk patients, such as those with prior
the same time, about 5% of patients with MI are sent myocardial infarction (MI), diabetes, or peripheral
home from the ER and results in 20% of malpractice vascular diseases, to determine if the chest pain is of
payout. coronary origin requiring further interventions. Mo-
dalities such as echocardiogram, nuclear perfusion
Guidelines such as TIMI Risk Score have been devel- imaging, and exercise stress testing have been used
oped to allow triage of chest pain patients. Patients to assess for ischemia in patients with chest pain.
are-classified as low-risk (TIMI score <3), interme- Advances in CT and MRI have allowed these two
diate risk (3 ≤ TIMI score < 5), or high risk (TIMI modalities to play an increasingly important and
score ≥ 5) requiring urgent cardiac catheterization complementary role in evaluation of CAD.
and interventions. As high-risk patients have clear
symptoms and require cardiac catheterization, non-
Chest Pain Evaluation: Complimentary Role of Cardiac CT and MR 127
Computed Tomography coronary arteries, grafts are characterized by less
In the past, cardiac imaging necessitated specialized cardiac motion, a wider luminal diameter, and fewer
equipment such as electron-beam CT. Advances in calcifications, allowing for reliable assessment of the
multi-detector CT have now allo wed for acquisition bypass grafts by MDCT. 16-slice MDCT shows PPV
of motion-free sub-millimeter resolution images of of 81% and NPV of 99% in detection of graft occlu-
the heart with ECG gating in one breath hold. ECG sion compared with invasive coronary angiography i.
gating also allows for cine imaging, assessing ven- Overall, 74% of the distal bypass anastamoses could
tricular contractile function by reconstruction of im- be visualized on MDCT. The causes of nonvisuali-
ages at different cardiac phases. The isotropic voxel zation of distal anastamoses are poor opacification,
nature of MDCT allows for ease of 3-dimensional metal clip artifacts, or cardiac motion artifacts.
multiplanar reconstructions (MPR) and volume ren-
dering techniques (VRT), increasing the diagnostic Detection of congenital anomalous coronary arteries
confidence. Due to high resolution and short acquisi- as a cause of chest pain is also another indication
tion time, ECG gated MDCT holds a distinct advan- for MDCT. The incidence of anomalous coronary
tage over cardiac MRI in morphological coronary artery ranges from 0.3 to 2.2% of the general popu-
imaging. lation j. A right coronary artery, or less commonly, a
left coronary artery which courses between the aor-
Coronary artery calcification (CAC) is associated tic root and the pulmonary trunk is a cause of acute
with underlying risk factors such as physical inac- myocardial infarction and sudden death in children
tivity, obesity, and is associated with increased risk and young adults. Compared to MDCT, invasive cor-
of MI as predicted by the Framingham criteria in onary angiography was able to diagnose only 55%
asymptomatic individuals a b. MDCT has been shown of the anomalous coronary arteries that were seen on
to be comparable to EBCT in determination of coro- MDCT k.
nary calcification c. In the setting of stable chest pain,
patients without ischemic EKG changes presenting MDCT has several limitations in evaluating CAD.
to the emergency room, a total calcium score of 0 The dose of radiation ranges from 0.45 mSv for
is associated with an annual cardiac event rate of < EKG-gated noncontrast calcium scoring to 7.1 mSv
1% over an average follow-up period of 50 months for ECG gated contrast coronary CT angiography
d
. The NPV of a calcium score of 0 was 0.97 for all with a 16-slice MDCT l. The dose for 64-slice car-
cardiac events 4. In patients less than 50 years old, diac CT is unfortunately higher, even with pulse
a small but significant number have significant an- modulation. The presence of arrhythmia also will
giographic CAD but do not have coronary calcifica- markedly decrease the quality of ECG gating and the
tion on CT e. Even in older patients with unknown corresponding quality of images. A high heart rate
CAD, up to 10% may have noncalcified plaques f. It above 70 will also decrease the diagnostic quality of
is therefore advisable that contrast should be used to the study. Other limitations include contrast adverse
evaluate significant stenoses caused by soft plaques, reactions and exacerbation of renal insufficiency. Ex-
especially in younger patients, if there is no contrain- tensive coronary calcification can also cause bloom-
dication. ing artifacts preventing adequate evaluation for sig-
nificant stenosis. The moderate positive predictive
Other indications of MDCT in chest pain evalua- value (≈75%) limits utility of MDCT for assessing
tion include evaluation for patency of bypass grafts significant obstruction of native coronary arteries in
g
. After 3 years, 20-30% of the bypass grafts can be high-risk patients secondary to coronary calcification
occluded. In a mean of 5 years after bypass surgery, as the major cause of false positive findings m n.
almost every third patient had an unexpected bypass
graft occlusion in a study h. It is therefore important
to detect graft occlusion early, as the clinical out-
come of the patients is closely related to the patency
rate of their bypass grafts. Compared with native
128 SECTION 3 Volumetric Cardiac Imaging
Cardiac Magnetic Resonance Imaging complex schemes such as the use of vector ECG are
Cardiovascular magnetic resonance (CMR) imag- needed for reliable R-wave detection compared to
ing has made dramatic progress since its inception MDCT 15.
in the 1980’s. Advancement in ultra-fast sequences
and parallel imaging techniques has now allowed for Direct visualization of the coronary arteries with
assessment of cardiovascular anatomy, global func- high-resolution CMR imaging generally required
tion, valvular status, perfusion status, myocardial much longer study acquisition time compared to
viability, and proximal to mid coronary anatomy in MDCT. Even with the use of subject specific adap-
a single image setting. Furthermore, compared to tive respiratory gating, the high-resolution (in-plane
MDCT, CMR does not involve ionized radiation or resolution 1.0mm x 0.78mm) coronary MRA acqui-
iodinated contrast. As CMR is a four-dimensional sition time was approximately 2.3 minutes for both
high resolution imaging technique, this allows for left and right coronary with vessel length imaged out
assessment of perfusion, infarction, and function at to approximately 8 mm for the right coronary artery
the subendocardial level not available in echocardi- and 6mm for the left coronary artery 17. The sensitiv-
ography or nuclear medicine. Contrast between dif- ity and specificity for detection of significant coro-
ferent tissue types can be changed by simply adjust- nary stenoses was 74.3% and 88.2% respectively in
ing the sequence parameters, i.e. T1 or T2 weighted, their study. Inability to image distal portions of coro-
without the need of any exogenous contrast. Intrave- nary arteries, especially that of the circumflex artery,
nous MRI contrast material can be injected to fur- is a limitation of coronary MRA 17 18. Detection of
ther delineate pathology, and to evaluate perfusion anomalous coronary arteries is, however, an excel-
and viability if needed. The risk of adverse reactions lent indication for coronary MRA due to the inherent
(such as anaphylatoid reaction or renal function ag- 3-D nature of coronary MRA and the need to only
gravation) to MRI contrasts is much lower than that visualize the proximal portions of the coronary arter-
of CT contrasts. Additionally, recent developments ies s (Bunce, Lorenz).
have allowed for acquisition of parameters such as
myocardial perfusion reserve and wall strain force The excellent temporal and spatial resolution of
that have only been available traditionally with in- CMR allows detection and quantitative evaluation of
vasive methods. The availability of cardiac MRI is ischemic heart disease at subendocardial level. Do-
however more limited compared to MDCT due to butamine stress MRI has been shown to have better
higher level of required expertise and preparation sensitivity (86% versus 74%), specificity (86% ver-
and examination time. sus 70%), and accuracy (86% versus 73%) compared
to dobutamine transthoracic echocardiography 20.
Similar to MDCT, CMR is very susceptible to arti-
facts caused by breathing and, therefore requires the Myocardial perfusion CMR imaging performed with
use of breath-hold sequences. Imaging of the coro- vasodilator infusion (such as adenosine or dypyrida-
nary arteries may require up to twenty 10-second mole) and gadolinium contrast injection allows for
breath-holds due to the required high resolution. The quantitative myocardial perfusion reserve measure-
variation between each breath-hold can also lead to ment. The increased signal in the myocardium due
image artifacts. Real-time “navigator” respiratory to contrast enhancement before and after vasodila-
gating has been developed to allow for coronary tor infusion can be quantified to provide indices
imaging 15. As with MDCT, CMR also relies on ac- such as myocardial perfusion reserve (MPR) 21. A
curate detection of QRS complex with ECG gating positive correlation (r=0.80, p<0.01) has been shown
to acquire images of the heart without blurring ar- between the reduced myocardial perfusion reserve
tifacts. In patients with frequent arrhythmia, retro- and reduced coronary flow reserve in patients with
spective ECG gated sequences are available, albeit microvascular dysfunction 22. The ability to non-in-
at the cost of longer breath-holds due to longer im- vasively provide myocardial perfusion reserve al-
aging time. Due to the magnetohydrodynamic effect lows for objective assessment of therapy efficacy in
from the flow of blood within a magnetic field, more patients with endothelial dysfunction such as those
Chest Pain Evaluation: Complimentary Role of Cardiac CT and MR 129
with diabetes, hypertension, syndrome X, and left Cardiac MRI has been shown to accurately assess
ventricular hypertrophy w x. the severity and the extent of myocardial necro-
sis and viability by the delayed hyperenhancement
A positive correlation (r=0.71, p<0.01) between my- imaging done 10-20 minutes after gadolinium con-
ocardial perfusion reserve and fractional flow reserve trast administration. In this technique, fibrosis and
(FFR) has also been shown. A myocardial perfusion infracted areas show increased signal intensity com-
reserve cutoff of 2.3 has a sensitivity of 88.9% (95% pared to surrounding normal myocardium. Studies
CI, 51.8-99.7%), and a specificity of 85.7% (95% CI, have shown correlation between the transmural ex-
42.1%-99.6%) in predicting a significantly decreased tent of the hyperenhancement and regional function-
FFR < 0.75 y. Myocardial perfusion reserve, there- al improvement following revascularization z. Even
fore, can also be utilized to predict possible need of thinned, severely hypokinetic myocardium has been
intervention in segmental ischemia. Currently, the shown to have functional improvement after revascu-
routine utilization of myocardial perfusion reserve larization if there is no delayed hyperenhancement aa.
is hindered by the current necessity for the user to An acute infarction can show a nonenhancing central
manually draw regions of interests to obtain regional region with peripheral enhancement due to microv-
perfusion indices over multiple slices. It is anticipat- ascular obstruction at the center. The presence of
ed that further software development will allow this this finding is associated with greater morbidity and
process to become more automated over time. impaired functional recovery ab. Compared to other
techniques such as SPECT and PET, cardiac MRI is
at least as accurate or slightly superior in predicting
functional improvement with the added advantage of
higher resolution allowing for detection of infarction
at the subendocardial level ac.
130 SECTION 3 Volumetric Cardiac Imaging
Complementary usage of cardiac Conclusion
CT and MRI Cardiac CT and MRI can be used in complementary
Complementary usage of cardiac CT and MRI ex- roles to evaluate chest pain patients non-invasively in
ploiting each modality’s advantages would provide a cost effective and expeditious manner. We antici-
the most effective evaluation of a patient presenting pate that further studies and future advancements in
with chest pain. the technology will increase their usage and utility in
the evaluation of chest pain patients.
Based on the above mentioned evidences, a strategy
using cardiac CT and MRI in a complementary fash- CASE PRESENTATIONS
ion is proposed, taken into account that the availabil-
ity and speed of cardiac CT is higher than that of Case 1 - COMPUTED TOMOGRAPHY/
cardiac MRI (Please refer to the diagram below): COMPUTED TOMOGRAPHY ANGIOGRAPHY
CHEST - CARDIAC STUDY.
A chest pain patient is triaged into low, intermedi-
ate, and high risk according to clinical findings, EKG ADDENDUM:
findings, and TIMI Risk Score. Those patients with On the provided images, there is also evidence of
positive cardiac markers, ST elevation, or high-risk significant amount of calcification distributed in the
TIMI score are directed to cardiac catheterization, as perihilar area as well as the AP window. In addition,
non-invasive imaging has no role in the management there are several small lymph nodes identified meas-
of these patients. Low-risk and intermediate-risk pa- uring up to 1 cm in size.
tients are evaluated with cardiac CT to risk stratify
and evaluate for significant occlusion of the coro- IMPRESSION:
nary arteries by soft plaques. If cardiac CT shows There is evidence of granulomatous disease of the
significant coronary stenosis, cardiac catheterization mediastinum as well as the perihilar structures. Sev-
is performed for early intervention, as the stenosis eral small lymph nodes are identified in the medias-
may be causing unstable angina. In low-risk pa- tinal area. If clinically indicated, a chest computed
tients with a cardiac CT negative for coronary cal- tomography study and/or chest x-ray study would be
cification and significant stenosis, the patient can be recommended.
discharged home and followed-up as an outpatient.
Patients showing significant coronary calcification CLINICAL HISTORY: The patient is a 51-year-old
on cardiac CT or classified as intermediate-risk, are male suffering from chest pain. He tested positive
further evaluated with stress/rest perfusion cardiac EKG for ischemia and was being evaluated for coro-
MRI. If ischemia is detected, cardiac MRI or cardiac nary artery disease.
catheterization can be performed.
Method:
Patients with risk factors for endothelial dysfunc- 16 multislice computed tomography scanning of
tion and syndrome X with a cardiac CT negative for the coronary arteries was performed. Calcium scor-
calcification and without significant obstruction are ing was assessed quantitatively with a precontrast
evaluated with cardiac MRI for findings of microvas- computed tomography scan with 2 mm thick slices
cular disease by measuring the myocardial perfusion covering the complete heart. Contrast bolus of a to-
reserve. Follow-up assessment can be performed tal of 90 cc Visipaque IV was injected to perform a
with cardiac MRI to evaluate the effectiveness of contrast enhanced coronary computed tomography
medical therapy optimization. angiogram without immediate side effects. 3-D re-
construction as well as multiplanar reconstruction
was performed using the Aquarius Workstation from
TeraRecon, Inc.
Chest Pain Evaluation: Complimentary Role of Cardiac CT and MR 131
Figure 1 No coronary calcium on CT scan. Multiple Figure 2a 3D Volume Rendering showing mid
classified nodes-granulomatous disease LAD stenosis
FINDINGS:
Calcium scoring: There is a 0 calcium score for
the right coronary artery and left coronary artery.
(Figure 1)
COMPUTED TOMOGRAPHY CORONARY
ANGIOGRAM:
LAD: At the mid aspect of the LAD, there is a 75%
to 80% significant narrowing. This lesion is located
between the first and the second perforator branch-
es. In addition, there is a significant amount of soft
plaque visualized. (Figures 2-5)
Figure 2b 3D Volume Rendering showing mid
LAD stenosis
132 SECTION 3 Volumetric Cardiac Imaging
Figure 3 MIP LAD Stenosis Figure 5a Angiogram of Heart. 75% mid LAD stenosis
Figure 4 CPR of LAD stenosis Figure 5b Angiogram of Heart. 75% mid LAD stenosis
Chest Pain Evaluation: Complimentary Role of Cardiac CT and MR 133
IMPRESSION:
1) Significant mid LAD coronary stenosis of 75
to 80%.
2) LAD Stenosis with significant soft plaque bur-
den.
CONCLUSIONS:
1. CORONARY STATUS: ASCAD: severe cul-
prit mid LAD coronary disease as assessed by
CTA.
2. LOW NORMAL LV Systolic Function.
After a brief discussion of the options, risks and ben-
efits the patient elected IVUS and PCI of the LAD,
Figure 6 MIP of LCX
which was recommended.
LCX: The LCX does not show significant coronary
artery stenosis in the first two-thirds of the coronary
artery segments. (Figure 6)
RCA: The right coronary artery does not show any
significant coronary stenosis of the first two-thirds of
the right coronary artery segments.(Figure 7)
Figure 7 MIP of RCA
134 SECTION 3 Volumetric Cardiac Imaging
Case 2 - CTA CARDIAC
HISTORY:
The patient is a 61-year-old female with onset of
chest pain in the morning hours. She was admitted to
the emergency room. The patient was then evaluated
for coronary artery disease.
Method: Non-contrast 16-slice multi detector CT
imaging of the heart was performed pre-contrast in
transverse slice position. Quantification of the cal-
cium score was available for interpretation. In addi-
tion, 16-slice multi detector coronary angiography
was performed injecting a total dose of 100 cc’s
Ultravist IV without immediate side effects. A dual
injector protocol was used. 3D post processing of the
coronary arteries was performed using the Aquarius
Figure 9a Angiogram of LAD, showing total proximal
Workstation from TeraRecon, Inc. The patient was
LAD occlusion
also administered a total of 10 mg Metoprolol with a
recorded heart rate of 50-60 beats per minute. The pa-
tient was stable hemodynamically during and shortly
after the exam. Her blood pressure was 160/90. CT angiography:
Left main coronary artery: There is no evidence of
FINDINGS: significant coronary artery stenosis within the left
Calcium scoring; There is significant calcification main coronary artery.
noted in the circumflex coronary artery as well as in
the LAD. Calcium score for the left main coronary LAD: There is evidence of a significant coronary ste-
artery is 11.0. The calcium score for the LAD is 66.2. nosis at the mid LAD (Figures 9, 10, 11, 12).
The calcium score for the circumflex is 252.7. The
calcium score for the right coronary artery is 63.1.
The total calcium score is 393.0 (Please refer to the
table below).
Equivalent Agatston
Artery Number of Lesions
Score
LM 1 11.0
LAD 2 66.2
CX 3 252.7
RCA 1 63.1
Total 7 393.0
Threshold = 130 HU
Figure 8 Calcium Scoring
Chest Pain Evaluation: Complimentary Role of Cardiac CT and MR 135
Figure 11 MIP of LAD
Figure 9b Angiogram of LAD, Left to right collaterals
from LAD to RCA
Figure 10 3D Volume Rendering of Heart, Severe Figure 12 MIP of LAD and LCX
LAD occlusion
136 SECTION 3 Volumetric Cardiac Imaging
Figure 13 MIP of LCX Figure 14b Angiogram of RCA
LCX: Coronary stenoses suggested in particular of NOTE: It is noted that during the contrast ejection,
the LCX side branches of indeterminate significance. there was evidence of a resting perfusion defect not-
( Figure 13) ed in the anterior, septal, apical area. This is sugges-
tive of a high degree stenosis/subtotal occlusion of
the LAD.
RCA: Suggested proximal right coronary stenosis of
indeterminate signficance. (Figures 14, 15) IMPRESSION:
The calcification is significant considering the age
of the patient. This is suggestive of a significantly in-
Figure 14a Angiogram of RCA, 80% Proximal Figure 15 MIP of RCA, Significant proximal
RCA stenosis RCA stenosis
Chest Pain Evaluation: Complimentary Role of Cardiac CT and MR 137
creased risk for major coronary events. Additionally,
there are evidences of a significant coronary steno-
sis/occlusion of the mid LAD, of coronary stenoses
of the RCA and LCX, and of a resting perfusion de-
fect in the anterior apical and anterior septal region
(Figure 16).
REST STRESS
Figure 16 MRI of heart, Large area of ischemia at inferolateral, inferior wall
138 SECTION 3 Volumetric Cardiac Imaging
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140 SECTION 3 Volumetric Cardiac Imaging
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