Comprehensive adenosine stress perfusion MRI defines the etiology of chest pain in the emergency room: Comparison with nuclear stress test

Abstract

Purpose-To compare standard of care nuclear SPECT imaging with cardiac magnetic resonance imaging (MRI) for emergency room (ER) patients with chest pain and intermediate probability for coronary artery disease.Materials and Methods-Thirty-one patients with chest pain, negative electrocardiogram (ECG), and negative cardiac enzymes who underwent cardiac single photon emission tomography (SPECT) within 24 h of ER admission were enrolled. Patients underwent a comprehensive cardiac MRI exam including gated cine imaging, adenosine stress and rest perfusion imaging and delayed enhancement imaging. Patients were followed for 14 ± 4.7 months.Results-Of 27 patients, 8 (30%) showed subendocardial hypoperfusion on MRI that was not detected on SPECT. These patients had a higher rate of diabetes (P = 0.01) and hypertension (P = 0.01) and a lower global myocardial perfusion reserve (P = 0.01) compared with patients with a normal cardiac MRI (n = 10). Patients with subendocardial hypoperfusion had more risk factors for cardiovascular disease (mean 4.4) compared with patients with a normal MRI (mean 2.5; P = 0.005). During the follow-up period, patients with subendocardial hypoperfusion on stress MRI were more likely to return to the ER with chest pain compared with patients who had a normal cardiac MRI (P = 0.02). Four patients did not finish the MR exam due to claustrophobia.Conclusion-In patients with chest pain, diabetes and hypertension, cardiac stress perfusion MRI identified diffuse subendocardial hypoperfusion defects in the ER setting not seen on cardiac SPECT, which is suspected to reflect microvascular disease. Keywordsadenosine stress perfusion cardiac MRI; emergency room; chest pain; microvascular disease The evaluation and triage of patients with chest pain is a common challenge for emergency room (ER) physicians. Fast and accurate assessment of myocardial ischemia in a patient * Address reprint requests to: J.V.-C., Johns Hopkins University, Department of Radiology, Nelson Basement MRI 143, 600 N Wolfe Street, Baltimore, MD 21287. jclauss1@jhmi.edu. New technical developments over the past decade allow a comprehensive cardiac MRI examination, which includes myocardial perfusion, function, and viability assessment (4,5). Stress perfusion with MRI is an emerging noninvasive method for the evaluation of myocardial ischemia (6-9). Myocardial scar imaging with MRI aids in identifying small subendocardial myocardial infarctions that are not seen by cardiac SPECT (10). Furthermore, cardiac SPECT exposes the patient to 17-20 mSv of ionizing radiation (11) that is not present with MRI. NIH Public AccessSome patients presenting to the ER with chest pain likely of cardiac origin may not have flow limiting stenosis of the coronary arteries, but instead have small vessel or other cardiac disease that could potentially be identified by . Therefore, the aim of this study was to compare standard of care nuclear SPECT imaging with cardiac MRI for the evaluation of emergency room patients with chest pain and intermediate pr...

Stress Cardiac MR Imaging Compared with Stress Echocardiography in the Early Evaluation of Patients Who Present to the Emergency Department with Intermediate-Risk Chest Pain

“…The present study extends the findings of previous investigations (21)(22)(23)(24)(25). Both Kwong et al (23) and Cury et al (21) showed the value of cardiac MR imaging in patients seen in the ED.…”

“…Moreover, there was no comparison with a separate stress imaging modality. Similar to the Ingkanisorn et al study, the investigations by Lerakis et al (24) and Vogel-Claussen et al (25) yielded encouraging findings regarding the utility of stress cardiac MR imaging; however, the former is a retrospective analysis and the latter included only 27 patients.…”

“…It is important to note that three (5%) patients could not undergo cardiac MR imaging because of limitations due to either body habitus or claustrophobia. The rate of patients unable to undergo MR imaging because of body habitus is low (21,23,25), but this is a practical disadvantage of stress cardiac MR imaging. Adenosine was used for stress cardiac MR imaging, but different methods (exercise or dobutamine) were used for stress echocardiography, which could have influenced the results.…”

A Magnetic Resonance Imaging–Conditional External Cardiac Defibrillator for Resuscitation Within the Magnetic Resonance Imaging Scanner Bore

“…MRI can also differentiate between chronic and acute infarcts 6 , so its use in triaging chest-pain in the emergency-room may grow 10, 11 .…”

Pharmacological Stress Cardiovascular Magnetic Resonance

“…Evaluating patients presenting to the ED with suspected ACS, Vogel-Claussen et al 65 studied the prognostic importance of the size and duration of perfusion defects identified during perfusion stress. In ED patients with chest pain at an intermediate probability for coronary artery disease, Vogel-Claussen et al 65 demonstrated that diffuse subendocardial hypoperfusion defects (less than half of the myocardial wall thickness in at least 2 different coronary artery territories of 6 beats in duration) were associated with return to the ED with chest pain compared with patients who had no CMR perfusion defect ( P = 0.02).…”