Background— Hemodynamically significant coronary artery disease is an important indication for revascularization. Stress myocardial perfusion imaging is a noninvasive alternative to invasive fractional flow reserve for evaluating hemodynamically significant coronary artery disease. The aim was to determine the diagnostic accuracy of myocardial perfusion imaging by single-photon emission computed tomography, echocardiography, MRI, positron emission tomography, and computed tomography compared with invasive coronary angiography with fractional flow reserve for the diagnosis of hemodynamically significant coronary artery disease.

Methods and Results— The meta-analysis adhered to the Preferred Reporting Items for Systematic Reviews and Meta-analyses statement. PubMed, EMBASE, and Web of Science were searched until May 2014. Thirty-seven studies, reporting on 4721 vessels and 2048 patients, were included. Meta-analysis yielded pooled sensitivity, pooled specificity, pooled likelihood ratios (LR), pooled diagnostic odds ratio, and summary area under the receiver operating characteristic curve. The negative LR (NLR) was chosen as the primary outcome. At the vessel level, MRI (pooled NLR, 0.16; 95% confidence interval [CI], 0.13–0.21) was performed similar to computed tomography (pooled NLR, 0.22; 95% CI, 0.12–0.39) and positron emission tomography (pooled NLR, 0.15; 95% CI, 0.05–0.44), and better than single-photon emission computed tomography (pooled NLR, 0.47; 95% CI, 0.37–0.59). At the patient level, MRI (pooled NLR, 0.14; 95% CI, 0.10–0.18) performed similar to computed tomography (pooled NLR, 0.12; 95% CI, 0.04–0.33) and positron emission tomography (pooled NLR, 0.14; 95% CI, 0.02–0.87), and better than single-photon emission computed tomography (pooled NLR, 0.39; 95% CI, 0.27–0.55) and echocardiography (pooled NLR, 0.42; 95% CI, 0.30–0.59).

Conclusions— Stress myocardial perfusion imaging with MRI, computed tomography, or positron emission tomography can accurately rule out hemodynamically significant coronary artery disease and can act as a gatekeeper for invasive revascularization. Single-photon emission computed tomography and echocardiography are less suited for this purpose.

Diagnostic Accuracy of Stress Myocardial Perfusion Imaging Compared to Invasive Coronary Angiography With Fractional Flow Reserve Meta-Analysis

Dynamic contrast-enhanced computed tomography (DCE-CT) and magnetic resonance imaging (DCE-MRI) are functional imaging techniques. They aim to characterise the microcirculation by applying the principles of tracer-kinetic analysis to concentration–time curves measured in individual image pixels. In this paper, we review the basic principles of DCE-MRI and DCE-CT, with a specific emphasis on the use of tracer-kinetic modeling. The aim is to provide an introduction to the field for a broader audience of pharmacokinetic modelers. In a first part, we first review the key aspects of data acquisition in DCE-CT and DCE-MRI, including a review of basic measurement strategies, a discussion on the relation between signal and concentration, and the problem of measuring reference data in arterial blood. In a second part, we define the four main parameters that can be measured with these techniques and review the most common tracer-kinetic models that are used in this field. We first discuss the models for the capillary bed and then define the most general four-parameter models used today: the two-compartment exchange model, the tissue-homogeneity model, the “adiabatic approximation to the tissue-homogeneity model” and the distributed-parameter model. In simpler tissue types or when the data quality is inadequate to resolve all the features of the more complex models, it is often necessary to resort to simpler models, which are special cases of the general models and hence have less parameters. We discuss the most common of these special cases, i.e. the uptake models, the extended Tofts model, and the one-compartment model. Models for two specific tissue types, liver and kidney, are discussed separately. We conclude with a review of practical aspects of DCE-CT and DCE-MRI data analysis, including the problem of identifying a suitable model for any given data set, and a brief discussion of the application of tracer-kinetic modeling in the context of drug development. Here, an important application of DCE techniques is the derivation of quantitative imaging biomarkers for the assessment of effects of targeted therapeutics on tumors.

Tracer-kinetic modeling of dynamic contrast-enhanced MRI and CT: a primer.

The assessment of CT perfusion images of the myocardium at one time point; the best dynamic semiquantitative parameter, upslope; and the quantitative parameter myocardial blood flow showed similar high diagnostic accuracy without significant differences compared with coronary angiography and fractional flow reserve measurement.

https://pubs.rsna.org/doi/pdf/10.1148/radiol.13121441

Myocardium: Dynamic versus Single-Shot CT Perfusion Imaging

Magnetic resonance imaging (MRI) has now been used clinically for more than 30 years. Today, MRI serves as the primary diagnostic modality for many clinical problems. In this article, historical developments in the field of MRI will be discussed with a focus on technological innovations. Topics include the initial discoveries in nuclear magnetic resonance that allowed for the advent of MRI as well as the development of whole-body, high field strength, and open MRI systems. Dedicated imaging coils, basic pulse sequences, contrast-enhanced, and functional imaging techniques will also be discussed in a historical context. This article describes important technological innovations in the field of MRI, together with their clinical applicability today, providing critical insights into future developments.

A Historical Overview of Magnetic Resonance Imaging, Focusing on Technological Innovations

Objectives This paper systematically analyzed the performance of magnetic resonance (MR) perfusion to diagnose coronary artery disease (CAD) with fractional flow reserve (FFR) as the reference standard Background Myocardial MR perfusion has passed the stage of a research technique and has demonstrated the ability to detect functional or ischemic stenosis of coronary arteries However, the evidence is limited to single-center studies and small sample sizes Methods We searched PubMed and Embase databases for all published studies that evaluated the accuracy of MR perfusion to diagnose CAD versus FFR We used an exact binomial rendition of the bivariate mixed-effects regression model with test type as a random-effects covariate to synthesize the available data Based on Bayes’ theorem, the post-test probability was calculated to guide MR perfusion’s clinical utility Results We identified 14 studies evaluating 1,073 arteries and 650 patients The pooled sensitivity and specificity were 090 (95% confidence interval [CI]: 086 to 093) and 087 (95% CI: 082 to 090) at the patient level and 089 (95% CI: 083 to 092) and 086 (95% CI: 077 to 092) at the artery and territory levels, respectively The area under the summary receiver-operating characteristic at the patient level was 095 (95% CI: 092 to 096) and 093 (95% CI: 091 to 095) at the artery and territory levels, respectively MR perfusion could increase the post-test probability of CAD >80% in patients with a pre-test probability of >37% and can decrease post-test probability of CAD  Conclusions With FFR as the reference standard, the diagnostic ability of MR perfusion to detect ischemic CAD is high

Diagnostic accuracy of myocardial magnetic resonance perfusion to diagnose ischemic stenosis with fractional flow reserve as reference: systematic review and meta-analysis.

The aim of this study was to investigate if a quantitative evaluation of a magnetic resonance (MR) perfusion examination of the myocardium can achieve a comparable diagnostic accuracy as a semiquantitative evaluation.A total of 31 patients with suspected coronary artery disease underwent MR imaging and conventional coronary angiography. Stenoses with a diameter reduction between 50% and 75% were evaluated by an intracoronary pressure wire examination (fractional flow reserve) for assessment of their hemodynamic relevance. A 0.05 mmol/kg contrast material bolus (gadopentetate dimeglumine) was applied during adenosine-induced stress (140 ?g/kg/min) and at rest with a flow rate of 5 mL/s. Signal intensity time curves of the first-pass MR perfusion images, acquired at rest and under adenosine stress with a Saturation Recovery-turbo Fast Low Angle Shot Magnetic Resonance Imaging sequence, were analyzed by Argus Dynamic Signal Analysis (Siemens Healthcare, Erlangen, Germany). For the semiquantitative evaluation, the upslope value of a linear fit from the foot point to the signal maximum was calculated for 18 segments (signal intensity units per second). For the quantitative evaluation, a model-independent deconvolution was used to calculate coronary blood flow (MBF in mL/100 g/min). For each segment for the stress and rest examination, upslope value and MBF were determined. In addition, the ratio of the stress and rest value for each segment was determined (myocardial perfusion reserve index [MPRI]). The mean value of the 2 segments with the lowest value was calculated for each patient. Coronary artery stenosis greater than 75% or greater than 50% with positive fractional flow reserve less than 0.75 was considered as hemodynamically relevant. Receiver-operator-curves were calculated.The values of the area under the ROC curves were 0.74, 0.66, and 0.92 for the US(Stress), US(Rest), and US(MPRI) evaluations (semiquantitative evaluation). The values for the MBF(Stress), MBF(Rest), and MBF(MPRI) evaluations (quantitative evaluation) were 0.92, 0.68, and 0.84, respectively. Comparing US(MPRI) and MBF(Stress), identical values and no significant difference were found for the area under the ROC curves.A quantitative evaluation using a model-free deconvolution provides identical diagnostic performance when only a stress examination is used, much similar to a semiquantitative evaluation, if both stress and rest examinations are used.

Magnetic resonance perfusion of the myocardium: semiquantitative and quantitative evaluation in comparison with coronary angiography and fractional flow reserve.

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Magnetic resonance perfusion of the myocardium: semiquantitative and quantitative evaluation in comparison with coronary angiography and fractional flow reserve.