Elsevier

Clinical Radiology

Volume 70, Issue 6, June 2015, Pages 576-584
Clinical Radiology

Review
Measuring myocardial perfusion: the role of PET, MRI and CT

https://doi.org/10.1016/j.crad.2014.12.017Get rights and content

Recently, focus has changed from anatomical assessment of coronary arteries towards functional testing to evaluate the effect of stenosis on the myocardium before intervention. Besides positron-emission tomography (PET), cardiac MRI (CMR), and cardiac CT are able to measure myocardial perfusion. Myocardial perfusion abnormalities are the first sign of the ischaemic cascade in the development of coronary artery disease (CAD). PET is considered the non-invasive clinical reference standard for absolute quantification of myocardial perfusion. The diagnostic and prognostic value of PET is well-known and is used in routine clinical practice. However, PET uses radioactive tracers and has a lower spatial resolution compared to CMR and CT. CMR and CT are emerging techniques in the field of myocardial perfusion imaging. CMR uses magnetic resonance to obtain images, whereas CT uses x-rays during first-pass of non-ionic and ionic contrast agents, respectively. Absolute quantification with CMR has yet to be established in routine clinical practice, while CT has yet to prove its diagnostic and prognostic value. The upcoming years may change the way we diagnose and treat patients suspected of having CAD with more precise methods for measuring myocardial perfusion. The aim of this comprehensive review is to discuss current and emerging imaging techniques used for myocardial perfusion imaging.

Introduction

The heart is an essential organ pumping blood and supplying all organs in the body with nutrients and oxygen, and carrying away waste products and carbon dioxide. The blood supply to the heart itself is provided by coronary arteries as suggested by Ibn Nafis in the 13th century, long before advanced imaging techniques were developed.1 A major disease of the coronary arteries is the formation of atherosclerosis, which slowly reduces the blood supply to the heart muscle. This mismatch between blood supply and oxygen demand of the myocardium can cause chest pain and dyspnoea on exertion in cold weather and in emotional stress situations. Moreover, this can result in acute myocardial infarction, chronic ischaemic heart disease, heart failure, and sudden cardiac death.

More than 7 million deaths worldwide are attributed to coronary artery disease (CAD), and this number is expected to increase more than threefold to 23.3 million by 2030 (http://www.who.int/mediacentre/factsheets/fs317/en/). According to the ischaemic cascade, myocardial perfusion abnormalities are the first sign in the development of CAD.2 This step precedes wall motion abnormalities, ECG changes, and angina. It has yet to be proven that early detection of myocardial perfusion abnormalities leading to aggressive intervention against cardiovascular risk factors and restoring myocardial perfusion may consequently reduce morbidity and mortality. Traditionally, the detection of myocardial perfusion abnormalities and the decision to intervene with revascularization has been based on the symptoms of the patient and single photon-emission CT (SPECT). However, the impact on the myocardium of significant coronary artery stenosis can also be measured by cardiac MRI (CMR) and CT.

Section snippets

Myocardial perfusion imaging

Invasive angiographic assessment of myocardial perfusion is expensive, time consuming, and requires skilled staff.3 However, besides diagnostic assessment of the coronary arteries with invasive coronary angiography (ICA), direct intervention on diseased coronary arteries is possible.4, 5 Although fractional flow reserve can be measured to define the degree of arterial stenosis, the viability of the supplied myocardium may not be revealed. Moreover, a non-negligible number of patients referred

Conclusion

There has been a shift during recent years from anatomical assessment of coronary arteries towards the functional impact of CAD on the myocardium. Currently, PET is considered the non-invasive clinical reference standard for absolute quantified myocardial perfusion and is often clinically used as a semi-quantitative assessment of myocardial perfusion. Table 1 summarizes the human studies comparing myocardial perfusion with ICA as reference.

CMR has a high spatial resolution and visual assessment

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