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Areas of delayed contrast-enhancement are frequent, either nodular predominating in the subepicardium or showing up as thick bands preferentially at mid-wall. Myocyte membrane rupture leading to increased extracellular space, oedema related to the inflammatory phenomenon with capillary compression, increased vascular permeability responsible for an increased distribution volume, along with decreased gadolinium clearance, may explain gadolinium accumulation in regions involved in the pathologic process of acute myocarditis. These lesions occur in the same territory as oedema and do not correspond to a known coronary territory see Figure 2.

These abnormal areas of delayed enhancement are very often localised in the inferolateral wall. More subtle patterns such as micro-nodular lesions can be observed.

After 10 days, subacute forms are more difficult to pick by CMR because of the diffusion of the viral process in the myocardium. The oedema may become more diffuse, as well as wall motion abnormality. Delayed enhancement may be difficult to highlight because of a more diffuse process. Several longitudinal studies have followed patients up to three months. A favourable outcome was observed when LV contractile function improved and paralleled a significant decrease or involution of damaged delayed-enhanced myocardial tissue.

Although still controversial, early hyperenhancement occurring four minutes after gadolinium injection at the acute phase and persisting up to one month after the onset of symptoms could be indicative of poor outcome. Recent works including only limited numbers of patients showed that delayed-enhanced ECG-gated cardiac MSCT acquired five minutes after injection can provide similar information to that of CMR, with an excellent correlation in terms of location and patterns of myocardial lesions. Also, limited numbers of clinical observations have been so far reported in the literature indicating that MSCT could accurately depict myocardial damage in acute myocarditis.

Although the contrast between damaged myocardium and remote tissue seems less pronounced with MSCT than CMR, this technique offers the advantage of non-invasive coronary angiography during the same examination, which may be of crucial importance for the exclusion of ACS in patients presenting with acute chest pain. It is well known that acute myocarditis can masquerade as acute MI. In the setting of acute chest pain with concomitant ST-segment elevation on at least two contiguous ECG leads, guidelines for management of ST-segment elevation MI should be applied.

When patients have a low risk profile for CAD and particularly if they have a recent history of fever or flu, the authors suggest that invasive coronary angiography should be the preferred method when rapidly available in order to avoid potentially inappropriate thrombolytic therapy. CMR should play an important role when coronary angiography rules out significant coronary stenosis in these cases and has the potential to confirm the diagnosis of myocarditis.

Although myocardial distribution of oedema is theoretically different, it is often difficult to distinguish between myocarditis and acute MI based on T2-weighted CMR images. As previously described, patterns of delayed hyper-enhancement are very distinct and help discriminate between acute MI and acute myocarditis see Table 1. In conclusion, functional CMR has routine clinical applications in the setting of myocardial ischaemia and infarction.

Besides accurate assessment of LV function and cardiac anatomy with cine-CMR, the study of myocardial perfusion permits the detection of microvascular obstruction after acute MI, which carries important prognostic implications. Contrast-enhanced CMR has become the clinical reference method for detection of myocardial viability after MI or in chronic ischaemic LV dysfunction. In addition, CMR is also becoming a reference diagnostic tool in suspected myocarditis.

The evolution of CMR patterns during the course of myocarditis may be of great interest for the establishment of prognosis especially in patients with initial LV dysfunction, heart failure, or with familial history of cardiomyopathy. Because of its great value for non-invasive coronary angiography, it is mandatory to prospectively evaluate different diagnostic strategies using these techniques alone or in combination in patients with suspected acute myocarditis. A version of this article containing references can be found in the Reference Section on the website supporting this briefing www.

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Noninvasive Imaging for Suspected CAD: Which Test When?

Search form Search this site. Current Author Addresses: Mr. Schuetz and Drs. Author Contributions: Conception and design: G.

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Schuetz, M. Analysis and interpretation of the data: G.

Schuetz, N. Zacharopoulou, P. Schlattmann, M. Critical revision of the article for important intellectual content: N. Final approval of the article: G. Abstract Background: Two imaging techniques, multislice computed tomography CT and magnetic resonance imaging MRI , have evolved for noninvasive coronary angiography. Data Extraction: 2 investigators independently extracted patient and study characteristics; differences were resolved by consensus.

Myocardial Perfusion Imaging Versus CT Coronary Angiography: When to Use Which?

Limitations: Few studies investigated coronary angiography with MRI. Primary Funding Source: None. Citations Citation. Published: Ann Intern Med. DOI: See Also. View More View Less. Left bundle branch block and coronary artery disease: accuracy of dipyridamole thallium single-photon emission computed tomography in patients with exercise anteroseptal perfusion defects. J Nucl Cardiol.

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J Dermatol Sci. Impaired myocardial flow reserve on rubidium positron emission tomography imaging predicts adverse outcomes in patients assessed for myocardial ischemia. Incremental prognostic value of gated Rb positron emission tomography myocardial perfusion imaging over clinical variables and rest LVEF. Senior R, Lahiri A. Dobutamine echocardiography predicts functional outcome after revascularisation in patients with dysfunctional myocardium irrespective of the perfusion pattern on resting thallium imaging.

Stress echocardiography for the diagnosis and risk stratification of patients with suspected or known coronary artery disease: a critical appraisal. Supported by the British Society of Echocardiography.

Myocardial Perfusion Imaging Versus CT Coronary Angiography: When to Use Which?

A meta-analysis of diagnostic test performance. Geleijnse ML, Elhendy A. Can stress echocardiography compete with perfusion scintigraphy in the detection of coronary artery disease and cardiac risk assessment? Eur J Echocardiogr.

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Coronary Angiography

Stress echo results predict mortality: a large-scale multicenter prospective international study. Prognostic value of normal stress echocardiogram in patients with suspected coronary artery disease — a British general hospital experience. Int J Cardiol. Myocardial contrast echocardiography evolving as a clinically feasible technique for accurate, rapid, and safe assessment of myocardial perfusion: the evidence so far. Detection of coronary artery disease by combined assessment of wall motion, myocardial perfusion and coronary flow reserve: a multiparametric contrast stress-echocardiography study.

J Am Soc Echocardiogr. Prognostic value of dobutamine stress myocardial perfusion echocardiography in patients with known or suspected coronary artery disease and normal left ventricular function. PLoS One. Comparison of two-dimensional speckle and tissue Doppler strain measurement during dobutamine stress echocardiography: an angiographic correlation. Two-dimensional speckle tracking for the assessment of coronary artery disease during dobutamine stress echo: clinical tool or merely research method. Cardiovasc Ultrasound. Real-time three-dimensional dobutamine stress echocardiography for coronary artery disease diagnosis: validation with coronary angiography.

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Standardized cardiovascular magnetic resonance CMR protocols update. J Cardiovasc Magn Reson. Assessment of advanced coronary artery disease: advantages of quantitative cardiac magnetic resonance perfusion analysis. Diagnostic accuracy of stress perfusion CMR in comparison with quantitative coronary angiography: fully quantitative, semiquantitative, and qualitative assessment. Diagnostic performance of noninvasive myocardial perfusion imaging using single-photon emission computed tomography, cardiac magnetic resonance, and positron emission tomography imaging for the detection of obstructive coronary artery disease: a meta-analysis.