Cardiac imaging with MRI,

CT and Nuclear techniques

Factfile No.1 January 2010
Summary

Cardiac magnetic resonance (CMR) is the gold standard for assessing cardiac anatomy, function and mass

CMR is not the technique of choice for non invasive imaging of the coronary arteries

Computed tomography (CT) provides rapid, high quality non-invasive imaging of the coronary arteries

CT calcium scoring provides diagnostic and prognostic information on coronary artery disease

Nuclear imaging has a role in evaluating myocardial perfusion

Cardiac Positron Emission Tomography (PET) imaging with FDG is the gold standard for assessment of myocardial viability

Conventional X-ray angiography remains essential for coronary intervention (angioplasty)

Background
Non-invasive cardiac imaging* has developed rapidly over recent years
and is set to play an important role in the assessment of cardiac structure
and function in the future. Several different technologies are involved
and it is important that the optimal, most cost-effective test for each
individual clinical situation is chosen. There is currently no single non
invasive imaging technique that can provide all the information needed
to manage heart disease.
Cardiovascular Magnetic Resonance (CMR)
Magnetic Resonance (MR) imaging relies on differences in the way
tissues react to a magnetic field, based largely on their water content, to
generate an image. Differences in the way the field is applied can
produce different types of image and information. Consequently, the
image provided by MR is a composite of the data acquired, usually as a
series of digital data sets representing only a small portion of the whole
heart, and how it is handled (processed) by the computer. Data
acquisition requires the presence of the patient, but data processing can
take place at a later time. CMR has lagged behind MR imaging of other
organs because of artefacts induced by cardiac and respiratory
movements that occur during data acquisition. However, ECG and
respiratory gating (where data acquisition is synchronized with the
cardiac and respiratory cycle) coupled with increasingly rapid data
acquisition technologies now allow data sets to be acquired in a single
breath hold. From data acquired over 40-60 minutes CMR now delivers
high-resolution images in any imaging plane that can be processed to
provide two or three-dimensional static reconstructions or movie loops
in almost every patient.
What is CMR good at?
CMR provides outstanding anatomical and functional detail.
Consequently its main clinical uses are:

to characterise congenital heart disease and its complications

to measure right and left ventricular mass (CMR is the gold standard
for quantifying left ventricular hypertrophy)

to differentiate forms of cardiomyopathies, such as hypertrophic

cardiomyopathy, arrhythmogenic right ventricular cardiomyopathy
and infiltrative diseases such as sarcoid and amyloid

to assess left and right ventricular function, regional wall motion

abnormalities, myocardial viability and myocardial perfusion. Areas
of myocardial infarction can be identified following administration
of intravenous gadolinium.

to identify stress induced myocardial ischaemia during infusions of

dobutamine or adenosine
*Some imaging procedures require the infusion or injection of agents to stress the
heart or those to enhance imaging such as nuclear imaging tests.
In addition, CMR has a role in the assessment of intra-cardiac masses and
quantifying intra- and extra-cardiac shunt flows. Because it can image
the entire aorta it is increasingly used for diagnosis and follow-up of
patients with several aortic pathologies e.g. dissection, Marfan and
aneurysm. However, although CMR can visualise the large proximal
portions of coronary arteries, such that it is used to diagnose rare
congenital anomalies of the coronaries, CMR currently cannot produce
images of sufficient quality to assess coronary artery disease.
What are the advantages of CMR over other imaging
techniques?
CMR provides higher resolution and clearer three dimensional images of
the heart than echocardiography, but at a substantially greater cost. It is
non-invasive, does not involve exposure to ionizing radiation and, unless
contrast agents are used, carries no known risks. It is highly reproducible
and therefore ideal for serial imaging.
What are the disadvantages of CMR?
CMR cannot be used in patients with large implanted metallic devices,
such as cardiac defibrillators or pacemakers (although there are some
MRI compatible pacing devices now available). However, patients with
modern mechanical heart valves or coronary artery stents can be
imaged safely.
CMR requires patients to lie inside a narrow tube for a considerable
amount of time. Consequently, some patients experience anxiety and
claustrophobia - this can sometimes be overcome by using sedation.
Image quality may be suboptimal in patients who are unable to hold
their breath or in those with an irregular heart rate, such as atrial
fibrillation. In patients with severe renal impairment gadolinium contrast
(used to image myocardial scarring) can lead to the rare complication of
nephrogenic systemic fibrosis.
State of the art CMR requires a highly trained multidisciplinary team,
including cardiologists, radiologists, radiographers and physicists. It is
therefore expensive and not yet available in all hospitals.
Cardiac Computed Tomography (CT)
Cardiac CT uses x-rays to build up 3D images of the heart. With modern
CT machines scans can be performed in under one second and can
provide remarkable levels of anatomical detail. CT imaging of the heart
can be performed either with or without intravenous contrast agents. As
with CMR, following acquisition, the CT datasets can be reformatted in
any orientation and can be viewed as cine loops for functional analysis
of ventricular function. Software allows semi-automated extraction of
the coronary arteries and the production of 3D volumetric datasets. Total
scan time for a cardiac CT is about 15 minutes.
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What is cardiac CT good at?

Coronary calcium scoring for suspected coronary artery disease

nearly all atherosclerotic plaques contain some calcium. Low dose,
non-contrast CT scans of the heart can quantify the amount and
distribution of calcium in the coronary arteries. There is a direct
correlation between the extent of calcium in the coronary arteries
and the risk of future cardiac events.

Diagnosis and assessment of coronary artery disease contrast

enhanced CT of the coronary arteries enables visualization of the
artery lumen, atherosclerotic plaques and stenoses. When combined
with calcium score, CT coronary angiography has a very high
negative predictive value (approaching 100%) for ruling out
coronary artery disease.

Assessment of patency of bypass grafts and anomalous coronary

arteries CT allows accurate assessment of coronary bypass graft
occlusion and patency, along with evaluation of the course of
anomalous coronary arteries.

Assessment of left ventricular mass and function accurate

assessment of stroke volume, ejection fraction and wall motion
abnormalities can be obtained.

Assessment of cardiac morphology CT can be used to assess

complex congenital heart disease; cardiac masses; thrombus;
pericardial disease; pulmonary and aortic pathology.
What are the advantages of CT over other imaging
techniques?
CT provides rapid, high quality imaging of the coronary arteries not
matched by any other non-invasive technique and is the only technique
able to provide a calcium score. CT scanning is less claustrophobic than
MRI and can be used in most patients who are precluded from having
CMR.
What are the disadvantages of CT?
The main disadvantage of cardiac CT is the dose of radiation, which is
dependent on the type of imaging undertaken, but is currently around
the same as a conventional x-ray angiogram (4-6mSv) for a full cardiac
investigation. The dose has fallen rapidly as the technology has
developed and is likely to fall still further in the future. As with routine X-
ray angiography, nephrotoxic iodinated contrast agents should be used
with caution in patients with impaired renal function.
Cardiac Nuclear Imaging - Single Photon Emission Computed
Tomography (SPECT) and Cardiac Positron Emission Tomography
and (PET)
Cardiac SPECT and PET are both non-invasive nuclear imaging
techniques. They rely on intravenous administration of radiotracers that
are extracted by normal myocardium, such as thallium and sestamibi for
SPECT and Fluorodeoxyglucose (FDG) for PET. Images are derived from
radioactive emission data acquired using either a gamma camera
(SPECT) or a PET scanner and processed to provide an image of the
radiotracer distribution in the myocardium. Both techniques generate
low resolution, high sensitivity 3D images of radiotracer distribution
within the myocardium. Their primary role is therefore in the quantative
assessment of myocardial perfusion and myocardial viability. They have
no role in anatomical imaging.
Both SPECT and PET data can be acquired during pharmacological stress
(adenosine, dipyridamole) to determine whether there are inducible
areas of ischaemia within the myocardium. Assessment of myocardial
ischaemia by SPECT involves comparing tracer distribution during stress
with that at rest. A mismatch indicates reversible ischaemia, whereas a
fixed defect indicates myocardial infarction. Consequently a SPECT
myocardial perfusion study requires two imaging sessions separated by
sufficient time to allow for decay of the previous dose. Cardiac SPECT is
much more widely available than PET and uses tracers with long half-
lives. In contrast cardiac PET is less available and uses short half life tracers
whose short half-life requires that they have to be generated near to the
scanner and used within a short time of production. The advantage of
PET is its ability to use many different tracers to interrogate several
aspects of myocardial pathophysiology. Whilst SPECT is available in most
UK hospitals, cardiac PET remains predominantly a research tool
confined to major academic centres.
Total scanning time is usually around 30 minutes. The data are displayed
in the three standard cardiac planes and may include both static and
dynamic images. Images can be read both qualitatively and
quantitatively.
Newly designed combined PET/CT scanners provide the opportunity to
acquire complimentary anatomical data such as CT coronary
angiography and functional data such as perfusion in a single imaging
session. This hybrid technique at present remains a research tool.
What is nuclear imaging good at?

Assessment of myocardial perfusion (SPECT)

Assessment of left ventricular ejection fraction

Assessment myocardial viability (PET) FDG-PET can identify viable

myocardium that is functioning poorly as a result of reduced
perfusion (hibernating myocardium) that would benefit from
revascularization.
What are the advantages of nuclear imaging over other imaging
techniques?
Cardiac PET imaging with FDG is the gold standard for assessment of
myocardial viability. Cardiac SPECT is relatively cheap and widely
available.
What are the disadvantages of nuclear imaging?
As with cardiac CT, nuclear imaging involves ionizing radiation. For
example, the radiation dose for a SPECT perfusion study is approximately
15mSv for a thallium scan. Consequently, nuclear imaging is not
appropriate for serial follow up studies.
Summary
Non invasive cardiac imaging is fast becoming the first line investigation
in the diagnosis and management of patients with heart disease.
Currently, there is no single technique that can provide all the
information that might be needed and choice of technique is dictated
by the question to be resolved and local availability and expertise. Both
cardiac MR and CT are set to become part of routine cardiac disease
management.
Further reading
1. Bandettini WP, Arai AE. Advances in clinical applications of cardiovascular magnetic resonance imaging. Heart 2008;94:1485-1495.
2. Roberts WT, Bax JJ, Davies LC et al. Cardiac CT and CT coronary angiography: technology and application. Heart 2008;94:781-792.
3. Hengel FM, Higuchi T, Javadi MS, Lautamki R. Cardiac Positron Emission Tomography. J Am Coll Cardiol 2009;54(1):1-15.