title: Anatomical versus functional assessment of coronary artery disease: direct comparison of computed tomography coronary angiography and magnetic resonance myocardial perfusion imaging in patients with intermediate pre-test probability.
abstract: Computed tomography coronary angiography (CTA) and cardiac magnetic resonance myocardial perfusion imaging (CMR-MPI) are state-of-the-art tools for noninvasive assessment of coronary artery disease (CAD). We aimed to compare the diagnostic accuracy of CTA and CMR-MPI for the detection of functionally relevant CAD, using invasive coronary angiography (XA) with fractional flow reserve (FFR) as a reference standard, and to evaluate the best protocol integrating these techniques for assessment of patients with suspected CAD. 95 patients (68 % men; 62 ± 8.1 years) with intermediate pre-test probability (PTP) of CAD underwent a sequential protocol of CTA, CMR-MPI and XA. Significant CAD was defined as >90 % coronary stenosis, 40-90 % stenosis with FFR ≤ 0.80 or left main stenosis ≥50 %. Prevalence of significant CAD was 43 %. CTA was more sensitive (100 %) but less specific (59 %) than CMR-MPI (88 and 89 %, respectively) for detection of significant CAD, with a strong trend for higher global diagnostic accuracy of CMR-MPI (88 vs. 77 %, p = 0.05). An integrated approach based on an initial CTA and subsequent referral to CMR-MPI of positive/inconclusive results had the best diagnostic performance (AUC 0.91). The direct referral to XA of patients with positive/inconclusive CTA performed worse than a selective approach based on CMR-MPI results (AUC 0.80 vs. 0.91, p = 0.005). In this intermediate PTP population, CMR-MPI showed a strong trend toward better performance compared to CTA for the assessment of functionally significant CAD. A combined protocol integrating coronary anatomy and function seems to be a very effective approach in the accurate diagnosis of CAD.
authors.affiliation: Cardiology Department, Centro Hospitalar de Vila Nova de Gaia/Espinho, Vila Nova de Gaia, Portugal, martacmponte@gmail.com.
authors.forename: Marta
authors.initials: M
authors.lastname: Ponte
authors.forename: Nuno
authors.initials: N
authors.lastname: Bettencourt
authors.forename: Eulália
authors.initials: E
authors.lastname: Pereira
authors.forename: Nuno Dias
authors.initials: ND
authors.lastname: Ferreira
authors.forename: Amedeo
authors.initials: A
authors.lastname: Chiribiri
authors.forename: Andreas
authors.initials: A
authors.lastname: Schuster
authors.forename: Aníbal
authors.initials: A
authors.lastname: Albuquerque
authors.forename: Vasco
authors.initials: V
authors.lastname: Gama
authors.forename: Eike
authors.initials: E
authors.lastname: Nagel
mesh_terms: D000328:Adult; D000368:Aged; D002138:Calibration; D017023:Coronary Angiography / Q000379:methods* / Q000592:standards; D003324:Coronary Artery Disease / Q000175:diagnosis* / Q000000981:diagnostic imaging / Q000503:physiopathology; D023921:Coronary Stenosis / Q000175:diagnosis* / Q000000981:diagnostic imaging / Q000503:physiopathology; D003331:Coronary Vessels / Q000000981:diagnostic imaging* / Q000503:physiopathology*; D005260:Female; D053805:Fractional Flow Reserve, Myocardial; D006801:Humans; D008279:Magnetic Resonance Imaging / Q000592:standards; D008297:Male; D008875:Middle Aged; D061330:Multidetector Computed Tomography / Q000592:standards; D055414:Myocardial Perfusion Imaging / Q000379:methods* / Q000592:standards; D011237:Predictive Value of Tests; D011446:Prospective Studies; D012015:Reference Standards; D015203:Reproducibility of Results; D012720:Severity of Illness Index
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