Noninvasive Imaging of Myocardial Ischemia

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Noninvasive Imaging of Myocardial Ischemia

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Constantinos D. Anagnostopoulos, Jeroen J. Bax, Petros Nihoyannopoulos and Ernst van der Wall

(Eds)

Noninvasive Imaging of Myocardial Ischemia

With 129 Figures

Including 45 Color Plates

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Constantinos D Anagnostopoulos, MD, PhD, FRCR, FESC Royal Brompton Hospital and

Chelsea & Westminster Hospital, London, UK, and

National Heart and Lung Institute, Imperial College School of Medicine, London, UK Petros Nihoyannopoulos, MD, FRCP, FACC, FESC

Imperial College, Hammersmith Hospital, London, UK Jeroen J. Bax, MD, PhD

Leiden University Medical Center, Leiden, The Netherlands Ernst van der Wall, MD, FESC, FACC

Leiden University Medical Center, Leiden, The Netherlands

British Library Cataloguing in Publication Data Noninvasive imaging of myocardial ischemia

1. Coronary heart disease – Imaging 2. Diagnostic imaging I. Anagnostopoulos, Constantinos D.

616.1¢23¢0754 ISBN-10: 1846280273

Library of Congress Control Number: 2005929229 ISBN-10: 1-84628-027-3 e-ISBN: 1-84628-156-3 ISBN-13: 978-1-84628-027-6

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To those who have devoted their lives to their patients and the art of medicine

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“. . . And if you ﬁnd her poor, Ithake won’t have fooled you. Wise as you will have become, so full of experience, you will have understood by then what these Ithakes mean.”

Konstantinos Kavaﬁs, Ithake, 1910

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Foreword I

ix

Noninvasive cardiac imaging is an integral part of the practice of current clinical cardiology. During the past three decades a number of distinctly different noninvasive imaging techniques of the heart, such as radionuclide imaging, echocardiography, magnetic resonance imaging, and X-ray computed tomography have been developed.

Remarkable progress has been made by each of these technologies in terms of technical advances, clinical procedures, and clinical applications/indications. Each technique was propelled by a devoted group of talented and dedicated investigators who explored the potential value of each technique for making clinical diagnoses and for deﬁning clinical characteristics of heart disease that might be most useful in the management of patients.

Thus far, most of these clinical investigations using various non-invasive cardiac imaging techniques were conducted largely in isolation from each other, often pursuing similar clinical goals. There now exists an embarrassment of riches of available imaging techniques and the potential for redundant imaging data. However, as each noninvasive cardiac imaging technique matured, it became clear that they were not necessarily competitive but rather complementary, each offering unique information under unique clinical conditions.

The development of each technique in isolation resulted in different clinical sub- cultures, each with its separate clinical and scientiﬁc meetings and medical literature.

Such a narrow focus and concentration on one technology may be very beneficial during the development stage of a technology, but once the basic practical principles have been worked out and clinical applications are established, isolation contains the danger of duplication of pursuits and scientific staleness when technology limits are reached. It should be obvious that each technique provides different pathophysiologic and/or anatomic information. Coming out of the isolation and cross-fertilization is the next logical step to evolve to a higher and more sophisticated level of cardiac imaging. Patients would benefit tremendously if each technique were to be used judiciously and discriminately, and provided just those imaging data needed to manage a specific clinical scenario. I anticipate that in the future a new type of cardiac imaging specialist will emerge. Rather than one-dimensional subspecialists, such as (I apologize) nuclear cardiologists or echocardiographers, multimodality cardiac imagers will be trained who have in-depth knowledge and experience of all available non-invasive cardiac imaging techniques. These imaging specialists will fully understand the value and limitations of each technique and will be able to apply each of them discriminately and optimally to the benefit of cardiac patients.

In Noninvasive Imaging in Myocardial Ischemia, the editors Drs. Anagnostopoulos, Nihoyannopolos, Bax, and Van der Wall, provide a wealth of information on the clinical value of various noninvasive cardiac imaging techniques. The editors collaborated with a distinguished group of authors – each recognized experts in their particular area of cardiac imaging. This book not only provides the reader with the present state of the art of currently available noninvasive cardiac imaging techniques, but also the comparative value (as far as information is available) of various techniques in different clinical

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x Foreword I

conditions and in different patient groups. After a general introduction to the pathophysiology of coronary artery disease as it relates to cardiac imaging, the first six chapters discuss the basic principles and technology of echocardiography, cardiac magnetic resonance imaging, radionuclide myocardial perfusion imaging, and computed X-ray tomography. Subsequent chapters deal with specific clinical conditions for which noninvasive cardiac imaging may be used. Unique to this book is that in each chapter the available evidence by alternative imaging techniques is discussed. In some chapters (Chapters 9–12), this consists merely of a comparison of stress radionuclide imaging and stress echocardiography, since no data are available for other imaging techniques. In other chapters (Chapters 7, 8, 13–15) data from the full spectrum of noninvasive cardiac imaging is available, and the authors discuss how it may be utilized to obtain optimal anatomic and pathophysiologic information relevant for patient management. Several chapters propose practical algorithms for stepwise testing by various imaging techniques in different patient cohorts. The editors and authors are to be applauded for their effort to come to grips with the difficult task of sorting out the relative and complementary value of each imaging technique. It is clear that much is not (yet) known and much work is still to be done. This well-illustrated and well-referenced book is a first step to clinical multimodality cardiac imaging and should be an invaluable resource for anyone interested in cardiac imaging. This book will be an important aid to cardiology fellows, nuclear medicine and radiology residents, cardiologists, radiologists, and nuclear medicine physicians who wish to take the step to multimodality, noninvasive cardiac imaging.

Frans J. Th. Wackers, MD Professor of Diagnostic Radiology

and Medicine Director, Cardiovascular Nuclear Imaging and Stress Laboratories Yale University School of Medicine New Haven, CT

USA

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Foreword II

xi

Noninvasive Imaging of Myocardial Ischemia provides a comprehensive discussion and review of the noninvasive myocardial imaging techniques that are currently available to detect myocardial ischemia and infarction. Topics covered include echocardiography, cardiac magnetic resonance imaging, myocardial perfusion scintigraphy, positron emission tomography, and computed tomography. There are also chapters on myocardial imaging techniques in the evaluation of asymptomatic individuals, prognostic assess- ments of patients with CAD by noninvasive imaging techniques, and imaging in the Emergency Department in patients with chest pain. Risk stratiﬁcation in patients with coronary heart disease, imaging techniques used to distinguish hibernating from irreversibly injured myocardium, and myocardial imaging in non-coronary and con- genital heart disease causes of myocardial ischemia are also discussed in the book. The chapters are comprehensive, informative, and written by experts in imaging of the myocardium.

This will be a very useful book for everyone interested in noninvasive myocardial imaging of ischemic heart disease. However, it will need to be updated with some frequency as one anticipates future advances with multidetector CT imaging, magnetic resonance imaging, detection of vulnerable atherosclerotic plaques, stem cell therapies, and the addition of nanotechnology methods to the evaluation and treatment of patients with coronary artery disease. Hopefully, the Editors will be able to provide periodic updates of the information available in this book, as well as of the new developments one anticipates.

James T. Willerson, MD President, The University of Texas Health Science Center President-Elect and Medical Director, Texas Heart Institute Houston, TX 77030 USA

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Preface

xiii

Noninvasive cardiac imaging covers a broad spectrum of investigations including echocardiography, radionuclide imaging, computed tomography (CT), and magnetic resonance imaging (MRI). Major developments have occurred in this ﬁeld recently and imaging data are now utilized almost on a daily basis for clinical decision making.

This book tries to capture the important advances and new directions in which the ﬁeld is heading. It provides a forum for a fertile discussion on the strengths and limitations of the various imaging modalities in different clinical settings offering also practical recommendations for their appropriate use. It focuses on the interrelations and complimentary roles of different techniques thus reﬂecting the multifaceted manifesta- tions of myocardial ischemia.

It is our belief that the ﬁeld of noninvasive cardiac imaging can only advance and strengthen its role in the decision-making process when comprehensive evidence-based information is used. We are very privileged that the contributors to this volume are inter- national opinion leaders in their ﬁeld. They have made every effort not only to provide state of the art information on their respective topics but also to keep alive the discussion on imaging as a whole. We hope that the book will be a very helpful reference for practi- tioners from different background and disciplines including cardiologists, general physicians and imagers.

The ﬁrst section (Chapters 1 to 6) discusses principles of pathophysiology relevant to noninvasive cardiac imaging and provides up to date information on the technical aspects of different imaging modalities. The second section (Chapters 7 to 15) focuses on the role of imaging in the assessment of myocardial ischemia offering valuable information on diagnostic and management issues, both within the stable and acute clinical setting. The accompanying CD contains 10 clinical cases and is designed to provide examples illustrating the clinical usefulness of noninvasive cardiac imaging in every day practice.

In a multi-authored book covering topics which are related to each other, a degree of overlap is inevitable. Every effort has been made to keep that to a minimum whilst main- taining at the same time the autonomy and completeness of each chapter.

We are indebted to all the contributors for their hard work and commitment to achieve this delicate balance and we wish to thank all of them for their superb chapters. We are very grateful to the staff of our departments for their contribution to the presentation of the images and cases of this book, to all those who supported our work and to the staff of Springer for their assistance and editorial advice.

C. Anagnostopoulos J.J. Bax P. Nihoyannopoulos E. Van der Wall

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List of Contributors

xvii

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W. Li, MD, PhD

Royal Brompton Hospital London, UK

Eric Tien Siang Lim, MRCP, MA Cantab Wellington Hospital

London, UK

C.Y. Loong, MBBS, MRCP Royal Brompton Hospital London, UK

Thomas H. Marwick, MBBS, PhD, FRACP, FACC

University of Queensland Princess Alexandra Hospital Brisbane, Australia

Tarun K. Mittal, MBBS

Royal Brompton & Harefield Hospital NHS Trust

London, UK Niko R. Mollet, MD Erasmus Medical Center Rotterdam, The Netherlands Eike Nagel, MD

German Heart Institute Berlin Berlin, Germany

K. Nieman, MD, PhD

Erasmus Medical Center – Thoraxcenter Rotterdam, The Netherlands

Petros Nihoyannopoulos, MD, FRCP, FACC, FESC

Imperial College London Hammersmith Hospital, NHLI London, UK

Roderic I. Pettigrew, PhD, MD National Institute of Biomedical

Engineering and Biological Imaging National Institutes of Health

Bethesda, MD, USA Don Poldermans, MD, PhD Erasmus Medical Centre Rotterdam, The Netherlands

Frank E. Rademakers, MD, PhD University Hospitals Leuven Catholic University Leuven Leuven, Belgium

Dhrubo Rakhit, MD University of Queensland Princess Alexandra Hospital Brisbane, Australia

Eliana Reyes, MD

National Heart and Lung Institute Imperial College

London, UK

Michael B. Rubens, MBBS, DMRD, FRCR Royal Brompton & Harefield Hospital

NHS Trust London, UK

Arend F.L. Schinkel, MD Thoraxcentre

Erasmus Medical Centre Rotterdam, The Netherlands Olaf Schouten, MD

Erasmus Medical Centre Rotterdam, The Netherlands Roxy Senior, MD, DM, FRCP, FESC,

FACC

Northwick Park Hospital and Institute for Medical Research

Harrow, Middlesex, UK Leslee J. Shaw, PhD

Cedars-Sinai Medical Center Los Angeles, CA, USA

Prem Soman, MD, PhD, MRCP Tufts-New England Medical Center and Tufts University School of Medicine Boston, MA, USA

Ju-Le Tan, MBBS, MRCP Royal Brompton Hospital London, UK

James E. Udelson, MD

Tufts-New England Medical Center and Tufts University School of Medicine Boston, MA, USA

xviii List of Contributors

Noninvasive Imaging of Myocardial Ischemia

Noninvasive Imaging of Myocardial Ischemia

Constantinos D. Anagnostopoulos, Jeroen J. Bax, Petros Nihoyannopoulos and Ernst van der Wall

Noninvasive Imaging of Myocardial Ischemia

Foreword I

Foreword II

Preface

Contents

List of Contributors