CT and CMR in Ischemic Heart Disease

Dweck MR, Williams MC, Moss AJ, Newby DE, Fayad ZA.
Computed Tomography and Cardiac Magnetic Resonance in Ischemic Heart Disease. J Am Coll Cardiol 2016;68:2201-2216.

This review paper describes the role of cardiac computed tomography (CCT) and cardiac magnetic resonance (CMR) imaging in patients with ischemic heart disease. The following are key points to remember:

  1. CCT allows accurate imaging of coronary artery atherosclerosis, including luminal stenosis severity, plaque burden, and adverse plaque characteristics. CMR permits characterization of left ventricular perfusion, function, and areas with infarction.
  2. Coronary calcium scoring by noncontrast CCT can be useful for risk stratification, but images only calcified plaque.
  3. Adverse plaque characteristics can be identified by contrast-enhanced CCT, and has good agreement with intravascular ultrasound. This can characterize plaque including plaque composition, positive remodeling, necrotic core, the napkin ring sign, and spotty calcification. Adverse plaque characteristics have been associated with an increased risk of future acute coronary syndrome, but assessment can be subjective. CMR has been evaluated for characterization of coronary artery plaque, but has significant technical challenges, which prevent routine clinical use.
  4. CCT can image coronary artery stenosis with high accuracy in comparison to invasive angiography, and is routinely available for clinical application. Coronary MR angiography has technical challenges, which limit accurate assessment of luminal stenosis, although it can be used to assess for anomalous coronary arteries without exposure to radiation.
  5. CMR can identify ischemia by assessing perfusion and wall motion with stress. CMR has high accuracy and excellent prognostic data in the evaluation of ischemia. Fractional flow reserve derived from CCT is promising for evaluation of ischemia, but requires further study.
  6. CMR has become a gold standard for imaging of myocardial infarction and viability. CCT has moderate accuracy to identify infarction, but CMR is preferred, as it does not require radiation and has superior imaging quality for tissue characterization.
  7. Barriers to the use of CCT and CMR include their expense, and limited and variable availability; CMR is particularly limited by the extended time required for both imaging and interpretation.
  8. CCT and CMR have improved our ability to image the coronary arteries and myocardium, and have the potential to further expand their clinical role with future advances.

Clinical Topics: Acute Coronary Syndromes, Invasive Cardiovascular Angiography and Intervention, Noninvasive Imaging, Interventions and ACS, Interventions and Coronary Artery Disease, Interventions and Imaging, Angiography, Computed Tomography, Echocardiography/Ultrasound, Magnetic Resonance Imaging, Nuclear Imaging

Keywords: Acute Coronary Syndrome, Angiography, Atherosclerosis, Constriction, Pathologic, Coronary Artery Disease, Coronary Stenosis, Diagnostic Imaging, Ischemia, Magnetic Resonance Imaging, Magnetic Resonance Spectroscopy, Myocardial Infarction, Myocardium, Plaque, Atherosclerotic, Tomography, X-Ray Computed, Ultrasonography

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