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Roles of Nuclear Cardiology, Cardiac Computed Tomography, and Cardiac Magnetic Resonance: Assessment of Patients with Suspected Coronary Artery Disease^*

¹ Departments of Imaging and Medicine, Cedars-Sinai Medical Center, Burns and Allen Research Institute, Los Angeles, California; ² Departments of Medicine and Radiological Sciences, David Geffen School of Medicine at UCLA, Los Angeles, California; ³ University of Southern California, School of Medicine, Los Angeles, California; ⁴ Heart Disease Prevention Program, Department of Medicine, University of California, Irvine, California; and ⁵ Department of Cardiology, St. Luke's Roosevelt Hospital Center, New York, New York

View larger version (51K): [in a new window]   FIGURE 1.  Examples of normal and abnormal coronary calcium scans obtained by electron beam tomography. LAD = left anterior descending coronary artery; LCX = left circumflex artery; RCA = right coronary artery.

View larger version (19K): [in a new window]   FIGURE 2.  Relationship between coronary calcium areas (mm) by electron beam tomography and atherosclerotic plaque areas by postmortem examination for each individual coronary artery in patients who died of noncardiac cause. (Adapted with permission from (18).)

View larger version (22K): [in a new window]   FIGURE 3.  Diagrammatic representation of progression of atherosclerosis as described by Glagov et al. (21). White area indicates presence of plaque, without consideration of distinction between calcified and noncalcified plaque. Positive remodeling during minimal and moderate phases of plaque buildup can occur without compromise of lumen. However, as plaque volume becomes large, the artery no longer enlarges at a rate sufficient to prevent narrowing of the lumen. Although this is a highly simplified illustration of a complex and variable process, this phenomenon is the likely explanation for the observation that the vast majority of calcified coronary plaques are not associated with coronary stenosis (Adapted with permission from (21).)

View larger version (92K): [in a new window]   FIGURE 4.  Example from our laboratory of normal coronary CTA using 16-slice MSCT scanner (Philips). LAD = left anterior descending coronary artery; LCX = left circumflex artery.

View larger version (142K): [in a new window]   FIGURE 5.  Published example of 16-slice CTA (Siemens) in 49-y-old male with chest pain and ischemic exercise electrocardiography. CTA revealed left anterior descending artery (LAD) stenosis and normal right coronary artery (RCA). (1a) Coronary angiography showing severe lesion in LAD. (1b) A volume-rendering technique of RCA (MDCT) axial slice visualizing high-grade lesion. (1c) MDCT 3-dimensional volume-rendering technique. (1d) MDCT curved multiplanar reconstruction. (2a) Coronary angiography of RCA. (2b) MDCT volume-rendering technique of RCA. Ao = aorta; DB = diagonal branch; LV = left ventricle; PT = pulmonary trunk; VB = ventricular branch. (Adapted with permission from (38).)

View larger version (39K): [in a new window]   FIGURE 6.  Exercise MPS in asymptomatic 70-y-old male diabetic shows mild decreased uptake in anterior and lateral walls. Overall the MPS study, including ventricular, was considered equivocal. ST = stress; TI = thallium.

View larger version (117K): [in a new window]   FIGURE 7.  EBT study at level of left main coronary artery of patient in Figure 6. There is severe calcification in the left main and LAD coronary arteries. CCS was 1,295 (87th percentile). On the basis of combined MPS and CCS information, patient underwent coronary angiography, which revealed 75% stenosis in left main artery and 60% stenosis in mid of LAD. Patient underwent successful CABG.

View larger version (99K): [in a new window]   FIGURE 8.  Case example from our laboratory shows concordant left circumflex territory perfusion defects on CMR and MPS. Short-axis perfusion images acquired during adenosine (left) and at rest (right) using first-pass CMR (top) and dual-isotope MPS (bottom) are shown. CMR images acquired during pharmacologic vasodilation revealed reduced image intensity in anterolateral wall (arrow) that was not present on rest CMR. Similarly, MPS tomograms at same short-axis level, obtained after sestamibi injection during the same adenosine stress as used for CMR, also revealed a reversible perfusion defect in anterolateral wall (arrow).