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Non-invasive diagnosis and risk stratification in coronary artery disease

Joint session with the ESC Working Group on Cardiovascular Magnetic Resonance

Cardiac Magnetic Resonance

During the recent Euroecho congress, I had the pleasure to co-chair with Prof. Rademakers the session entitled: “Non invasive diagnosis and risk stratification in coronary artery disease”.

In a very elegant way, the speakers (Profs. Pierard, Plein,Pugliese and Kitsiou) showed all the advantages of the different non-invasive techniques in the evaluation of patients with coronary artery disease (CAD).

Stress echocardiography is widely available, highly versatile and non expensive. It can be performed at the bedside, and gives no radiation exposure but does require training and expertise. Stress echocardiography, as all anatomical and functional tests, should not be performed for screening in asymptomatic subjects. It is recommended (class I, level of evidence A) in patients with an intermediate pre-test likelihood of obstructive disease.
Exercise echocardiography should be performed throughout exercise and recovery. Left ventricular opacification by a contrast agent is useful when the endocardial definition is unsatisfactory. Cardiac magnetic resonance imaging (CMR) is preferable when echogenicity is low. The titration of a positive test is an advantage as it measures the extent, the severity and the timing of wall motion abnormalities. New technologies are also available (such as tissue Doppler imaging, speckle tracking, myocardial contrast echo) but are not yet recommended. The results of exercise echocardiography provide incremental risk stratification.
In summary, stress echo is highly validated, but other imaging modalities are required when echogenicity is poor, when the interpretation is difficult or when there is discordance between stress echocardiography and clinical data.

SPECT myocardial perfusion imaging (MPI) has been in use for more than 30 years as a non-invasive imaging technique. All major international guidelines recommend SPECT MPI for the diagnosis of CAD in patients with intermediate pre-test probability of CAD. The sensitivity for CAD diagnosis increases when quantitative image- analysis is performed. The specificity increases when Tc-99m labeled tracers, electrocardiogram (ECG) gating and attenuation correction are used.
A great amount of data has accumulated on the prognostic value of SPECT MPI. It has been shown in many studies that the rate of cardiac death and non-fatal myocardial infarction is strongly related to the extent and severity of the reversible perfusion defects (ischemia). Patients with more extensive ischemia yield a greater benefit from revascularization compared with medical therapy. In contrast, patients with normal SPECT MPI have a low risk of hard cardiac events. SPECT MPI is also used for evaluation of medical therapy, after percutaneous coronary intervention (PCI) or coronary artery bypass graft surgery, and for the assessment of myocardial viability.
Cardiovascular magnetic resonance (CMR) provides useful data for both chronic and acute presentations of CAD. In patients with suspected stable angina, CMR can diagnose CAD by either dobutamine stress CMR, which is very similar to dobutamine stress echocardiography, or vasodilator stress myocardial perfusion CMR. Perfusion CMR has the advantage of high spatial resolution and lack of ionsing radiation when compared with the more commonly used nuclear perfusion methods. Moreover, recent, large, single- and multicentre studies suggest that it has at least a comparable accuracy to that of SPECT.
In acute coronary syndromes, CMR can be used after initial therapy such as PCI, to help risk stratification by assessing infarct size, extent of myocardial salvage, as well as identifying microvascular obstruction and intramyocardial haemorrhage. In summary, CMR is a highly versatile and accurate test for the diagnosis and risk-stratification of CAD and the evidence base for its use in clinical practice is increasing. It should always be considered as an alternative to nuclear imaging methods where both are locally available.



There is no doubt that cutting edge information was provided and more questions arose for future research in this session.




Non-invasive diagnosis and risk stratification in coronary artery disease

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.

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