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Influence of small caliber coronary arteries on the diagnostic accuracy of adenosine stress cardiac magnetic resonance imaging.

Pilz G, Heer T, Graw M, Ali E, Klos M, Scheck R, Zeymer U, Höfling B - Clin Res Cardiol (2010)

Bottom Line: After adenosine infusion, myocardial first-pass sequence using gadolinium-based contrast agent was performed and compared with rest perfusion.We found a significant association between FP CMR and the presence of a small caliber coronary vessel (proximal diameter < one standard deviation below the mean) supplying the area of ischemia (chi-square 42.6, p < 0.0001).Small caliber coronary arteries found as normal variations in right-dominant or left-dominant circulation may account for hypoperfusion in the absence of coronary stenosis and thus may cause FP adenosine stress CMR results.

View Article: PubMed Central - PubMed

Affiliation: Department of Cardiology, Clinic Agatharied, Academic Teaching Hospital, University of Munich, Norbert-Kerkel-Platz, Hausham, Germany. pilz@khagatharied.de

ABSTRACT

Background and aims: Positive predictive value (PPV) of adenosine stress cardiac magnetic resonance (CMR) for coronary artery disease (CAD) is unsatisfactory. We investigated the impact of coronary caliber variability on this limitation in CMR performance.

Methods and results: 206 consecutive patients with myocardial ischemia during CMR and subsequent coronary angiography (CA) were studied. Patients were examined in a 1.5-T scanner. After adenosine infusion, myocardial first-pass sequence using gadolinium-based contrast agent was performed and compared with rest perfusion. CAD was invasively confirmed in 165 [true positive (TP); PPV, 80.1%] and ruled out in 41 patients [false positive (FP)]. TP and FP were comparable for pre-test risk and CMR findings. We found a significant association between FP CMR and the presence of a small caliber coronary vessel (proximal diameter < one standard deviation below the mean) supplying the area of ischemia (chi-square 42.6, p < 0.0001). A small caliber artery ipsilateral to the ischemic region was a predictive parameter for FP versus TP discrimination (ROC area, 0.84 ± 0.04 vs. 0.59 ± 0.05; p < 0.0001). Further increment in diagnostic accuracy was achieved by including proximal ipsilateral/contralateral coronary diameter ratios (ROC area, 0.90 ± 0.03; p < 0.03).

Conclusions: Small caliber coronary arteries found as normal variations in right-dominant or left-dominant circulation may account for hypoperfusion in the absence of coronary stenosis and thus may cause FP adenosine stress CMR results. Non-invasive assessment of proximal coronary diameters in the vessel supplying the area of ischemia could reduce FP rates, raise the diagnostic accuracy of CMR for CAD and minimize subsequent superfluous CA.

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Related in: MedlinePlus

CMR and CA findings in a FP perfusion result. Inferoseptal ischemia (a) as FP perfusion CMR result in a patient without coronary artery stenoses but small caliber RCA (b) and left-dominant circulation (c)
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Fig2: CMR and CA findings in a FP perfusion result. Inferoseptal ischemia (a) as FP perfusion CMR result in a patient without coronary artery stenoses but small caliber RCA (b) and left-dominant circulation (c)

Mentions: In comparison of TP and FP CMR results, we found significantly smaller sized mean proximal coronary artery diameters in the FP group (Fig. 1b). With a mean proximal coronary diameter of 3.5 mm and SD of 0.5 mm, our criterion for classification of a vessel as small caliber was a proximal diameter of <3.0 mm. The presence of such a small caliber coronary vessel (mean proximal diameter 2.5 ± 0.3 mm) supplying the area of maximal ischemia in CMR, opposite to the dominant vessel, was encountered in 22/41 (53.7%) of the FP cases. Compared to TP cases [1/165 (0.6%)], this incidence was significantly higher (chi-square 42.6, p < 0.0001). FP ischemia territory was supplied in 17/22 (77.3%) cases with right-dominant circulation by a small caliber LAD (n = 7) or LCX (n = 10) and in 5/22 (22.7%) by the RCA in left-dominant circulation. Figure 2 shows an example of FP CMR with inferolateral ischemia in a patient with left-dominant circulation and small caliber RCA.Fig. 2


Influence of small caliber coronary arteries on the diagnostic accuracy of adenosine stress cardiac magnetic resonance imaging.

Pilz G, Heer T, Graw M, Ali E, Klos M, Scheck R, Zeymer U, Höfling B - Clin Res Cardiol (2010)

CMR and CA findings in a FP perfusion result. Inferoseptal ischemia (a) as FP perfusion CMR result in a patient without coronary artery stenoses but small caliber RCA (b) and left-dominant circulation (c)
© Copyright Policy
Related In: Results  -  Collection

Show All Figures
getmorefigures.php?uid=PMC3040827&req=5

Fig2: CMR and CA findings in a FP perfusion result. Inferoseptal ischemia (a) as FP perfusion CMR result in a patient without coronary artery stenoses but small caliber RCA (b) and left-dominant circulation (c)
Mentions: In comparison of TP and FP CMR results, we found significantly smaller sized mean proximal coronary artery diameters in the FP group (Fig. 1b). With a mean proximal coronary diameter of 3.5 mm and SD of 0.5 mm, our criterion for classification of a vessel as small caliber was a proximal diameter of <3.0 mm. The presence of such a small caliber coronary vessel (mean proximal diameter 2.5 ± 0.3 mm) supplying the area of maximal ischemia in CMR, opposite to the dominant vessel, was encountered in 22/41 (53.7%) of the FP cases. Compared to TP cases [1/165 (0.6%)], this incidence was significantly higher (chi-square 42.6, p < 0.0001). FP ischemia territory was supplied in 17/22 (77.3%) cases with right-dominant circulation by a small caliber LAD (n = 7) or LCX (n = 10) and in 5/22 (22.7%) by the RCA in left-dominant circulation. Figure 2 shows an example of FP CMR with inferolateral ischemia in a patient with left-dominant circulation and small caliber RCA.Fig. 2

Bottom Line: After adenosine infusion, myocardial first-pass sequence using gadolinium-based contrast agent was performed and compared with rest perfusion.We found a significant association between FP CMR and the presence of a small caliber coronary vessel (proximal diameter < one standard deviation below the mean) supplying the area of ischemia (chi-square 42.6, p < 0.0001).Small caliber coronary arteries found as normal variations in right-dominant or left-dominant circulation may account for hypoperfusion in the absence of coronary stenosis and thus may cause FP adenosine stress CMR results.

View Article: PubMed Central - PubMed

Affiliation: Department of Cardiology, Clinic Agatharied, Academic Teaching Hospital, University of Munich, Norbert-Kerkel-Platz, Hausham, Germany. pilz@khagatharied.de

ABSTRACT

Background and aims: Positive predictive value (PPV) of adenosine stress cardiac magnetic resonance (CMR) for coronary artery disease (CAD) is unsatisfactory. We investigated the impact of coronary caliber variability on this limitation in CMR performance.

Methods and results: 206 consecutive patients with myocardial ischemia during CMR and subsequent coronary angiography (CA) were studied. Patients were examined in a 1.5-T scanner. After adenosine infusion, myocardial first-pass sequence using gadolinium-based contrast agent was performed and compared with rest perfusion. CAD was invasively confirmed in 165 [true positive (TP); PPV, 80.1%] and ruled out in 41 patients [false positive (FP)]. TP and FP were comparable for pre-test risk and CMR findings. We found a significant association between FP CMR and the presence of a small caliber coronary vessel (proximal diameter < one standard deviation below the mean) supplying the area of ischemia (chi-square 42.6, p < 0.0001). A small caliber artery ipsilateral to the ischemic region was a predictive parameter for FP versus TP discrimination (ROC area, 0.84 ± 0.04 vs. 0.59 ± 0.05; p < 0.0001). Further increment in diagnostic accuracy was achieved by including proximal ipsilateral/contralateral coronary diameter ratios (ROC area, 0.90 ± 0.03; p < 0.03).

Conclusions: Small caliber coronary arteries found as normal variations in right-dominant or left-dominant circulation may account for hypoperfusion in the absence of coronary stenosis and thus may cause FP adenosine stress CMR results. Non-invasive assessment of proximal coronary diameters in the vessel supplying the area of ischemia could reduce FP rates, raise the diagnostic accuracy of CMR for CAD and minimize subsequent superfluous CA.

Show MeSH
Related in: MedlinePlus