CT angiography with cardiac MRI: non-invasive functional and anatomical assessment for the etiology in newly diagnosed heart failure

Abstract

Exclusion of ischemia is important in patients with newly diagnosed systolic heart failure (HF). We prospectively compared standard-of-care invasive catheter angiography (iCA) and echocardiography to a novel non-invasive strategy of both Coronary Computed Tomographic Angiography (CCTA) and Cardiovascular MRI (CMR) to determine the etiology of myocardial dysfunction Prospective data were collected from consecutive patients referred for iCA to investigate echocardiographically-confirmed new onset HF. CMR (1.5T GE) and dual source CCTA were performed within 2-7 days of iCA. Results were blinded and separately analyzed by expert readers. 426 coronary segments from 28 prospectively enrolled patients were analyzed by CCTA and quantitative iCA. The per-patient sensitivity and specificity of CCTA was 100% and 90%, respectively, negative predictive value (NPV) 100%, positive predictive value (PPV) 78%. Mean ejection fraction by CMR was 24%. Presence of ischemic-type LGE on CMR conferred a 67% sensitivity, 100% specificity, 90% NPV and 100% PPV. Combining CCTA with CMR conferred 100% specificity, 100% sensitivity, 100% PPV and 100% NPV for detection or exclusion of coronary disease. In patients with negative CCTA all invasive angiograms could have been avoided. In addition, two patients with no ischemic LGE by CMR had severe coronary disease on both CCTA and iCA, indicating global hibernation. This is a noteworthy finding in contrast to previous reports which suggested that absence of LGE rules out significant CAD. CCTA with CMR in newly-diagnosed HF enables non-invasive assessment of coronary artery disease, the severity and etiology of myocardial dysfunction and defines suitability for revascularization. Absence of ischemic-type LGE at CMR does not exclude CAD as a cause of LV dysfunction. A first-line strategy of functional and anatomic imaging with CMR and CCTA appears appropriate in newly diagnosed HF.

Comparison of Electric- and Magnetic-Cardiograms Produced by Myocardial Ischemia in Models of the Human Ventricle and Torso

“…This suggests that the 12-lead ECG provides insufficient information for satisfactory diagnosis of ischemia. Other non-invasive techniques, including radionuclide methods [9], magnetic resonance imaging [10] and positron computed tomography [11], are far more sensitive to the detection of ischemia. However, they are highly expensive and time consuming, and therefore not practical for day-to-day, bedside monitoring and detection of silent ischemia (i.e.…”

Korean Guidelines for the Appropriate Use of Cardiac CT

“…In patients newly diagnosed with heart failure, it is important to rule out ischemic heart disease and coronary CT angiography has been shown to have this utility (68, 69, 70, 71, 72). Bhatti et al (73) performed a meta-analysis of 6 studies and included 452 patients to show that coronary CT angiography was useful in the diagnosis of ischemic heart disease.…”

Letter by Hamilton-Craig et al Regarding Article, “Role of Cardiovascular Magnetic Resonance as a Gatekeeper to Invasive Coronary Angiography in Patients Presenting With Heart Failure of Unknown Etiology”

“…In our relatively small, prospective study of similar patients with new heart failure undergoing coronary angiography and CMR, 2 of 28 patients (7%) had absence of late gadolinium enhancement but presence of severe obstructive coronary disease (left main and/or 3-vessel). 2 One patient was revascularized with full functional recovery, and the other is awaiting cardiac transplantation because of intractable heart failure. The fact that 2 such patients were found in our study, but none in Assomull et al or indeed previous reports, is simply a reflection of the relatively small cohorts in these studies.…”