J Cardiovasc Ultrasound.  2016 Jun;24(2):96-103. 10.4250/jcu.2016.24.2.96.

The Use of Cardiac Magnetic Resonance in Patients with Suspected Coronary Artery Disease: A Clinical Practice Perspective

• Chang SA
• Kim RJ

• KMID: 2308694
• DOI: http://doi.org/10.4250/jcu.2016.24.2.96

Abstract

Cardiac magnetic resonance imaging (CMR) is a useful diagnostic imaging modality in patients with known or suspected coronary artery disease (CAD). It provides unique information not available from other modalities, however, it is complex. CMR is not a single technique. Instead, it consists of multiple distinct techniques and a lack of understanding of which techniques to perform and how to interpret the findings in combination limits its efficacy and widespread use. Conversely, its multiparametric nature can provide a comprehensive assessment with the potential for higher accuracy than is achievable by other modalities. Moreover, its ability to directly assess myopathic processes often contributes insights that change patient management. In this article we provide a brief technical overview and focus on specific clinical scenarios in patients with known or suspected CAD. We highlight the multiparametric nature of CMR and discuss cases which illustrate the unique information that CMR can contribute.

Keyword

Cardiac magnetic resonance imaging; Coronary artery disease

MeSH Terms

Coronary Artery Disease*
Coronary Vessels*
Diagnostic Imaging
Humans
Magnetic Resonance Imaging

Figure

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  Fig. 1 Timeline and potential components of a multitechnique CMR examination including stress and rest perfusion imaging. Note that the entire exam can be performed within 30–45 minutes. In cases where the patient is unable to cooperate, the cine examination can be performed with real-time imaging and delayed enhancement with single-shot techniques. This technique will reduce artifacts in patients unable to breath-hold and total exam time will be shortened further. Adapted from Kim et al. J Am Coll Cardiol 2009;55:1-16, with permission of Elsevier.1) CMR: cardiac magnetic resonance imaging, MI: myocardial infarction, MRA: magnetic resonance angiography, SNR: signal to noise ratio, ECV: extra-cellular volume fraction.

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  Fig. 2 Interpretation algorithm for incorporating delayed enhancement-cardiac magnetic resonance imaging (DE-CMR) with stress and rest perfusion magnetic resonance imaging (MRI) for the detection of coronary disease. A: Schema of the interpretation algorithm. 1) Positive DE-CMR study: hyperenhanced myocardium consistent with a prior myocardial infarction (MI) is detected. Does not include isolated midwall or epicardial hyperenhancement which can occur in nonischemic disorders. 2) Standard negative stress study: no perfusion defects at stress or rest. 3) Standard positive stress study: perfusion defects are present with adenosine that are absent or reduced at rest. 4) Artifactual perfusion defect: matched stress and rest perfusion defects without evidence of prior MI on DE-CMR. B: Patient examples. Top row: patient with a positive DE-CMR study demonstrating an infarct in the inferolateral wall (red arrows) although perfusion-MRI is negative. The interpretation algorithm classifies this patient as positive for coronary artery disease (CAD). Coronary angiography verified disease in a circumflex marginal artery. Middle row: patient with a negative DE-CMR study but with a prominent reversible defect in the anteroseptal wall on perfusion-MRI (red arrows). The interpretation algorithm classifies this patient as positive for CAD. Coronary angiography demonstrated a proximal 95% LAD stenosis. Bottom row: patient with a matched stress-rest perfusion defect (blue arrows) but without evidence of prior MI on DE-CMR. The interpretation algorithm classifies the perfusion defects as artifactual. Coronary angiography demonstrated normal coronary arteries. Adapted from Klem et al. J Am Coll Cardiol 2006;47:1630-8, with permission of Elsevier.14) LCX: left circumflex artery, LAD: left anterior descending.

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  Fig. 3 Cine and delayed-enhancement images in a patient without signs or symptoms of coronary artery disease who was believed to have a structurally normal heart. Images demonstrate a focal subendocardial infarct (arrows) with normal left ventricular size and systolic function. CMR: cardiac magnetic resonance imaging, DE: delayed enhancement.

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  Fig. 4 The cartoon schematic on the left demonstrates multiple islands of hyperenhancement in a diffuse, near global pattern, which is classic for particular types of viral myocarditis. In other words, the correct interpretation of this pattern would be "non-CAD-type". In contrast, it would be incorrect to judge the pattern on the right, which shows only a few "dots" of hyperenhancement in a limited, focal territory, as non-CAD-type. CAD: coronary artery disease, DE: delayed enhancement.

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  Fig. 5 Typical delayed enhancement-cardiac magnetic resonance (DE-CMR) images from 3 patients with chest discomfort, ST-segment elevation, positive troponins, and normal invasive coronary angiograms. A: Linear, epicardial hyperenhancement (yellow arrows) is present and is indicative of myocarditis. B: Cine and DE images of a patient with sudden emotional stress and apical ballooning; the absence of hyper-enhancement is consistent with Takotsubo cardiomyopathy. C: Focal but transmural hyperenhancement (red arrow) involving the lateral apex is present and indicative of myocardial infarction (MI) because of temporary occlusion of a small diagonal branch off the distal left anterior descending coronary artery. DE-CMR with a long inversion time (600 ms) shows a thrombus (yellow arrowhead) in the left atrial appendage, suggesting that an embolus led to the MI.

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  Fig. 6 A 57-year-old patient with paroxysmal atrial fibrillation undergoing cardiac magnetic resonance imaging (CMR) prior to radiofrequency ablation procedure. A: Echocardiogram demonstrated normal left ventricular (LV) size and function and only mild LV wall hypertrophy. B: Delayed enhancement-CMR images demonstrated widespread hyperenhancement (arrows) primarily in a non-coronary artery disease-type pattern, which suggested an infiltrative process.

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