Combined Assessment of Coronary Anatomy and Myocardial Perfusion Using Multidetector Computed Tomography for the Evaluation of Coronary Artery Disease

Multidetector computed tomography (MDCT) is increasingly used as an alternative to invasive coronary angiography. Although computed tomographic coronary angiography (CTCA) has been validated against invasive coronary angiography and nuclear myocardial perfusion imaging, the potential of MDCT to evaluate perfusion has not been fully explored. We sought to (1) develop a new technique for quantitative assessment of myocardial enhancement based on analysis of MDCT images acquired for CTCA, (2) identify the underlying causes of myocardial hypoenhancement detected by MDCT, and (3) determine the added diagnostic value of the MDCT perfusion index when combined with CTCA. We studied 84 patients undergoing clinical CTCA (64 patients with invasive coronary angiogram and a control group of 20 patients). MDCT perfusion index was calculated from x-ray attenuation measured in 16 myocardial segments. Hypoenhancement was automatically detected using comparisons with the normal range obtained in the control group, and its added value was determined against invasive coronary angiographic findings combined with known previous myocardial infarction. Myocardial hypoenhancement was detected in 29 of 64 patients in 47 vascular territories, of which 36 (77%) were abnormal by the reference technique. Of these 36 abnormalities, 10 (28%) were associated with previous myocardial infarction, whereas 26 (72%) corresponded to significant coronary stenosis. The addition of MDCT perfusion index to CTCA improved its diagnostic accuracy (sensitivity 0.87 to 0.96, accuracy 0.84 to 0.88, despite a decrease in specificity 0.79 to 0.68). In conclusion, myocardial hypoenhancement is a potentially valuable addition to MDCT evaluation of coronary artery disease without additional cost in radiation dose or contrast load.