Assessment of cardiac ischaemia and viability: role of cardiovascular magnetic resonance

Juerg Schwitter, Andrew E Arai, Juerg Schwitter, Andrew E Arai

Abstract

Over the past years, cardiovascular magnetic resonance (CMR) has proven its efficacy in large clinical trials, and consequently, the assessment of function, viability, and ischaemia by CMR is now an integrated part of the diagnostic armamentarium in cardiology. By combining these CMR applications, coronary artery disease (CAD) can be detected in its early stages and this allows for interventions with the goal to reduce complications of CAD such as infarcts and subsequently chronic heart failure (CHF). As the CMR examinations are robust and reproducible and do not expose patients to radiation, they are ideally suited for repetitive studies without harm to the patients. Since CAD is a chronic disease, the option to monitor CAD regularly by CMR over many decades is highly valuable. Cardiovascular magnetic resonance also progressed recently in the setting of acute coronary syndromes. In this situation, CMR allows for important differential diagnoses. Cardiovascular magnetic resonance also delineates precisely the different tissue components in acute myocardial infarction such as necrosis, microvascular obstruction (MVO), haemorrhage, and oedema, i.e. area at risk. With these features, CMR might also become the preferred tool to investigate novel treatment strategies in clinical research. Finally, in CHF patients, the versatility of CMR to assess function, flow, perfusion, and viability and to characterize tissue is helpful to narrow the differential diagnosis and to monitor treatment.

Figures

Figure 1
Figure 1
A schematic explains the various time points of image acquisition relative to contrast medium administration to assess ischaemia and necrosis/scar tissue. Red line corresponds to normal non-ischaemic myocardium, blue line the ischaemic myocardium, black line the necrotic tissue in the acute myocardial infarction (fibrotic tissue in chronic myocardial infarction), and purple line the tissue with microvascular obstruction (MVO).
Figure 2
Figure 2
Example of a 70-year-old female patient with atypical chest pain and mild dyspnoea during exercise. Risk factors were hypercholesterolaemia and diabetes. The patient performed at 100% of predicted workload without symptoms and with a normal stress electrocardiogram (mildly ascending 0.07 mV ST depression) and without arrhythmias. Perfusion-cardiovascular magnetic resonance detects severe ischaemia in all vascular territories. Coronary angiography confirmed a triple-vessel disease and the patient was treated successfully by multiple stenting.
Figure 3
Figure 3
Diagnostic performance of perfusion-cardiovascular magnetic resonance to detect coronary artery disease (defined as ≥50% stenosis in invasive coronary angiography) in comparison vs. SPECT. Performance of SPECT in MR-IMPACT is comparable to those of previous multicentre SPECT trials (given as squares and circles) reported by Zaret et al., Van Train et al., and Hendel et al. Better performance is obtained with perfusion-cardiovascular magnetic resonance vs. SPECT [P < 0.013, in multivessel disease (MVD) P < 0.006]. Modified from Schwitter et al. with permission of Oxford Press.
Figure 4
Figure 4
Prediction of cardiac death and non-fatal myocardial infarction by assessment of ischaemia in seven large studies comprising more than 20 000 patients. In patients without ischaemia, outcome is excellent.
Figure 5
Figure 5
Viability assessment by late gadolinium enhancement (A) demonstrates the absence of necrosis (lack of bright tissue) in the hypo-akinetic anterior wall [end-systolic image in (B)]. As expected, the follow-up assessment by cardiovascular magnetic resonance demonstrates a major recovery of contractile function in the anterior wall [(C) end-systolic images at follow-up]. The late gadolinium enhancement technique is also sensitive for detection of thrombus, which is attached to a small necrotic (=bright) area in the apex of the left ventricle (A).
Figure 6
Figure 6
Tissue characterization by cardiovascular magnetic resonance. On the left-hand side (A and C), late gadolinium enhancement is applied to delineate tissue necrosis as bright areas (red arrows). In the canine experiment, a small subendocardial necrosis is detected, whereas in the patient with acute myocardial infarction (C), a dark core in the centre of necrosis is indicating the presence of microvascular obstruction. On the right, T2-weighted images show increased signal in the myocardium, indicating the presence of oedema, which corresponds to the area at risk. In the patient (D), dark areas in the centre of oedematous tissue indicate haemorrhage. The oedematous tissue [bright on T2-weighted images in (B) and (D)], i.e. the area at risk minus the necrotic tissue [in (A) and (C), respectively] yields the amount of salvaged myocardium.
Figure 7
Figure 7
Performance of different imaging techniques to detect acute coronary syndromes in acute chest pain patients. Data are derived for cardiovascular magnetic resonance from references,– for computed tomographic angiography from references,– and for SPECT from references.,–

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