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Controversies in Stress Imaging

Non-invasive Imaging: Magnetic Resonance Imaging

The Session on Controversies in stress saw the participation of exceptional 4 speakers experts in diverse stress imaging modalities.
Dr Richard Underwood presented a critical overview of the current literature on myocardial perfusion imaging describing the pro&con of nuclear imaging and cardiovascular magnetic resonance in patients with stable coronary artery disease. Although recognizing the methodological robustness of the CE-MARC study (Greenwood, Lancet 2012) (which highlighted the better diagnostic accuracy of perfusion CMR versus SPECT), he pointed out that this study was conducted in a single highly qualified centre and not necessarily applicable to real-world clinical practice. This has led to a lively discussion Dr Greenwood (chair of the session) who strongly disagree with this statement and argued the opposite. Dr Underwood also showed the advancement in SPECT technology with the introduction of solid-state camera which allows a substantial advancement in spatial resolution and concomitant reduction in radiation exposure.  He concluded that SPECT imaging is effective and cost-effective in the evaluation of patients with stable chest pain, whereas in his opinion perfusion CMR is effective in expert hands and its cost-effectiveness remains to be assessed.
Dr Eike Nagel elegantly reviewed stress perfusion imaging technique by CMR. He showed the pro&con of the various perfusion sequences, underlying the importance to recognise artefacts. He emphasized that the progressive implementation of the perfusion sequences is increasing leading to improved spatial and temporal resolution, which minimizes artefacts and improve the accuracy and robustness of perfusion CMR.  He described the MR-INFORM trial, which aims to determine whether perfusion CMR is non-inferior to coronary angiography with fractional flow reserve (FFR) in guiding management in stable chest pain patients. This trial holds the potentiality to change the diagnostic work-up of patients with stable ischemic heart disease. He also mentioned the ongoing ISCHEMIA trial which will also provide novel insight on the role of non-invasive imaging in patient with ischemic heart disease.
Dr Orlando Simonetti elegantly presented the promising results of exercise stress CMR. The method is based on conventional stress test performed on a treadmill beside the MRI scanner, followed by the acquisition of perfusion CMR and ‘real time’ cine images. The preliminary data indicates that the stress protocol is safe and accurate. The ongoing multicentre study of exercise stress CMR vs SPECT will provide more insight on the potential of exercise CMR in terms of safety, feasibility and diagnostic accuracy.
Dr Koen Nieman made an interesting overview on the state-of-the-art of cardiac computed tomography (CT) with particular emphasis on the recent applications of static and dynamic myocardial perfusion. The functional info added to the anatomical angiographic info leads to an increased specificity of this imaging technique to detect significant coronary artery disease.
Dynamic perfusion CT can measure the blood and myocardial attenuation over time deriving semi-quantitative parameters of myocardial perfusion. However, this technique is associated with a relatively high radiation dose and limited coverage of the left ventricle, whereas static perfusion, currently more validated, gives a snapshot of myocardial perfusion during maximal pharmacological vasodilatation. Finally Dr Nieman illustrated the recent advanced on non-invasive quantification of fractional flow reserve using conventional CT angiography. The DE FACTO and NTX trials show encouraging results on the robustness and accuracy of this novel technique, not ready yet for clinical applicability.


Controversies in Stress Imaging
The content of this article reflects the personal opinion of the author/s and is not necessarily the official position of the European Society of Cardiology.