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Detection of myocardial ischaemia

The evidence for use of contrast in clinical echocardiography: Myocardial Contrast Echocardiography – MCE


90% of myocardial blood volume is found in the capillaries [22] and the concentration of microbubbles within the myocardium is reflected by the contrast signal [23]. When the myocardium is fully saturated during contrast infusion, the signal intensity thus reflects the capillary blood volume. If these microbubbles are intentionally destroyed by a high power ultrasonic signal, the rate at which the capillaries replenish (refill with microbubbles) can be observed visually (qualitative assessment) or calculated using off-line software (quantitative assessment) [23]. Blood flows through myocardial capillaries at 1mm/second and an ultrasound beam has an elevation width of 5mm, meaning that it takes about 5s for replenishment of the myocardium. A decrease in coronary blood flow will thus manifest as prolonged replenishment of microbubbles during destruction-replenishment imaging [24].

Intuitively, tissue blood flow is determined by the amount of blood (capillary blood flow) and the speed at which it moves (red blood cell velocity). Therefore, myocardial blood flow (MBF) is calculated as:

Myocardial Blood Flow = Myocardial blood volume X Speed of myocardial flow
Peak contrast intensity X Peak microbubble velocity


STUDY n CAD present (%) MCE Sensitivity MCE Specificity
Aggeli et al [25] 532 413 (78) 92 61
Chiou et al [26] 132 85 (64) 81 77
Cwaig et al [27] 45 32 (71) 87 66
Elhendy et al [28] 170 127 (73) 91 51
Hayat et al [29] 63 25 (40) 92 95
Heinle et al [30] 15 12 (80) 75 67
Jeetley et al [31] 123 96 (78) 84 56
Karavidas et al [32] 47 11 (23) 91 92
Korosoglou et al [33] 89 62 (70) 83 72
Lin et al [34] 40 25 (63) 84 93
Malm et al [35] 43 33 (77) 77 72
Moir et al [36] 90 48 (53) 93 65
Olszowska et al [37] 44 44 (100) 97 93
Peltier et al [38] 35 22 (63) 85 (QL), 97 (QN) 79 (QL), 79 (QN)
Rocchi et al [39] 12 12 (100) 89 100
Senior et al [40] 55 43 (78) 86 88
Senior et al [41] 52 22 (42) 82 97
Shimoni et al [10] 44 28 (64) 75 100
Tsutsui et al [42] 16 13 (81) 64 (RT), 41 (TR) 92 (RT), 96 (TR)
Winter et al [43] 36 35 (97) 81 67
TOTAL 1683 1345 (80)    
MEAN [95% CI]     83 [78-88] 80 [73-87]

Table 1: The accuracy of MCE for detection of coronary artery disease (CAD) (QL = Qualitative; QN = Quantitative; RT = Real-Time; TR = Triggered imaging; CI = Confidence Interval – from Senior et al [16])

Additionally, a multi-centre, international phase III study of over 600 patients – with all image interpretation performed off site by independent readers – found MCE non-inferior to SPECT [44]. Another recent study comparing adenosine MCE with adenosine CMR in 65 patients with suspected CAD undergoing angiography found a sensitivity of 85%, specificity of 76% and overall diagnostic accuracy of 82% for detection of CAD, which was comparable with adenosine CMR [45].

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