Anatomical versus functional assessment of coronary artery disease: direct comparison of computed tomography coronary angiography and magnetic resonance myocardial perfusion imaging in patients with intermediate pre-test probability

• Published in: International Journal of Cardiovascular Imaging 2014-12, Vol.30 (8), p.1589-1597
• Main Authors: Ponte, Marta, Bettencourt, Nuno, Pereira, Eulália, Ferreira, Nuno Dias, Chiribiri, Amedeo, Schuster, Andreas, Albuquerque, Aníbal, Gama, Vasco, Nagel, Eike
• Format: Article
• Language: English
• Subjects: Adult; Aged; Calibration; Cardiac Imaging; Cardiology; Coronary Angiography - methods; Coronary Angiography - standards; Coronary Artery Disease - diagnosis; Coronary Artery Disease - diagnostic imaging; Coronary Artery Disease - physiopathology; Coronary Stenosis - diagnosis; Coronary Stenosis - diagnostic imaging; Coronary Stenosis - physiopathology; Coronary Vessels - diagnostic imaging; Coronary Vessels - physiopathology; Female; Fractional Flow Reserve, Myocardial; Humans; Imaging; Magnetic Resonance Imaging - standards; Male; Medicine; Medicine & Public Health; Middle Aged; Multidetector Computed Tomography - standards; Myocardial Perfusion Imaging - methods; Myocardial Perfusion Imaging - standards; Original Paper; Predictive Value of Tests; Prospective Studies; Radiology; Reference Standards; Reproducibility of Results; Severity of Illness Index
• ISSN: 1569-5794; 1573-0743; 1875-8312
• DOI: 10.1007/s10554-014-0492-y

Computed tomography coronary angiography (CTA) and cardiac magnetic resonance myocardial perfusion imaging (CMR-MPI) are state-of-the-art tools for noninvasive assessment of coronary artery disease (CAD). We aimed to compare the diagnostic accuracy of CTA and CMR-MPI for the detection of functionally relevant CAD, using invasive coronary angiography (XA) with fractional flow reserve (FFR) as a reference standard, and to evaluate the best protocol integrating these techniques for assessment of patients with suspected CAD. 95 patients (68 % men; 62 ± 8.1 years) with intermediate pre-test probability (PTP) of CAD underwent a sequential protocol of CTA, CMR-MPI and XA. Significant CAD was defined as >90 % coronary stenosis, 40–90 % stenosis with FFR ≤ 0.80 or left main stenosis ≥50 %. Prevalence of significant CAD was 43 %. CTA was more sensitive (100 %) but less specific (59 %) than CMR-MPI (88 and 89 %, respectively) for detection of significant CAD, with a strong trend for higher global diagnostic accuracy of CMR-MPI (88 vs. 77 %, p  = 0.05). An integrated approach based on an initial CTA and subsequent referral to CMR-MPI of positive/inconclusive results had the best diagnostic performance (AUC 0.91). The direct referral to XA of patients with positive/inconclusive CTA performed worse than a selective approach based on CMR-MPI results (AUC 0.80 vs. 0.91, p  = 0.005). In this intermediate PTP population, CMR-MPI showed a strong trend toward better performance compared to CTA for the assessment of functionally significant CAD. A combined protocol integrating coronary anatomy and function seems to be a very effective approach in the accurate diagnosis of CAD.