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Improved Detection of Coronary Artery Disease by Stress Perfusion Cardiovascular Magnetic Resonance With the Use of Delayed Enhancement Infarction Imaging

Igor Klem, MD^_*,, John F. Heitner, MD^_*, Dipan J. Shah, MD^_*, Michael H. Sketch, Jr, MD^_*, Victor Behar, MD^_*, Jonathan Weinsaft, MD^_*, Peter Cawley, MD^_*, Michele Parker, RN, MS^_*, Michael Elliott, MD^_*, Robert M. Judd, PhD^_* and Raymond J. Kim, MD^_*,_*

^_* Duke Cardiovascular Magnetic Resonance Center, Durham, North Carolina
Robert-Bosch-Krankenhaus, Stuttgart, Germany

View larger version (14K): [in a new window]   Figure 1 Interpretation algorithm for the diagnosis of coronary artery disease (CAD). (a) Positive delayed enhancement-cardiovascular magnetic resonance (DE-CMR) study: hyperenhanced myocardium consistent with a prior myocardial infarction (MI) is detected. Does not include isolated midwall or epicardial hyperenhancement, which can occur in nonischemic disorders (21,22). (b) Standard negative stress study: no evidence of prior MI or inducible perfusion defects. (c) Standard positive stress study: no evidence of prior MI, but perfusion defects are present with adenosine that are absent or reduced at rest. (d) Artifactual perfusion defect: matched stress and rest perfusion defects without evidence of prior MI on DE-CMR.

View larger version (120K): [in a new window]   Figure 2 Patient examples. (Top row) Patient with a positive DE-CMR study demonstrating an infarct in the inferolateral wall (arrow) although perfusion-CMR is negative. The interpretation algorithm (step a) classified this patient as positive for CAD. Coronary angiography verified disease in a circumflex marginal artery. Cine-CMR demonstrated normal contractility. (Middle row) Patient with a negative DE-CMR study but with a prominent reversible defect in the anteroseptal wall on perfusion-CMR (arrow). The interpretation algorithm (step c) classified this patient as positive for CAD. Coronary angiography demonstrated a proximal 95% left anterior descending coronary artery (LAD) stenosis. (Bottom row) Patient with a matched stress-rest perfusion defect (arrows) but without evidence of prior MI on DE-CMR. The interpretation algorithm (step d) classified the perfusion defects as artifactual. Coronary angiography demonstrated normal coronary arteries. Abbreviations as in Figure 1.

View larger version (21K): [in a new window]   Figure 3 Diagnostic performance of clinical and CMR predictors of obstructive CAD. Receiver-operating-characteristic curve analysis comparing the interpretation algorithm with perfusion-CMR alone and with clinical parameters for the detection of CAD. The interpretation algorithm provided the highest diagnostic performance. CRP = C-reactive protein; other abbreviations as in Figure 1.