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      Clinical quantitative cardiac imaging for the assessment of myocardial ischaemia

      , 1 , 2 , 3 , 4 , 5 , 6 , 7 , 8 , 1 , 9 , 10 , 10 , 11 , 11 , 12 , 1 , 13 , 14 , 15 , 16 , 17 , 18 , 19 , 20 , 20 , 21 , 21 , on behalf of the Quantitative Cardiac Imaging Study Group

      Nature Reviews. Cardiology

      Nature Publishing Group UK

      Ischaemia, Magnetic resonance imaging, Computed tomography, Positron-emission tomography, Echocardiography, Radionuclide imaging

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          Cardiac imaging has a pivotal role in the prevention, diagnosis and treatment of ischaemic heart disease. SPECT is most commonly used for clinical myocardial perfusion imaging, whereas PET is the clinical reference standard for the quantification of myocardial perfusion. MRI does not involve exposure to ionizing radiation, similar to echocardiography, which can be performed at the bedside. CT perfusion imaging is not frequently used but CT offers coronary angiography data, and invasive catheter-based methods can measure coronary flow and pressure. Technical improvements to the quantification of pathophysiological parameters of myocardial ischaemia can be achieved. Clinical consensus recommendations on the appropriateness of each technique were derived following a European quantitative cardiac imaging meeting and using a real-time Delphi process. SPECT using new detectors allows the quantification of myocardial blood flow and is now also suited to patients with a high BMI. PET is well suited to patients with multivessel disease to confirm or exclude balanced ischaemia. MRI allows the evaluation of patients with complex disease who would benefit from imaging of function and fibrosis in addition to perfusion. Echocardiography remains the preferred technique for assessing ischaemia in bedside situations, whereas CT has the greatest value for combined quantification of stenosis and characterization of atherosclerosis in relation to myocardial ischaemia. In patients with a high probability of needing invasive treatment, invasive coronary flow and pressure measurement is well suited to guide treatment decisions. In this Consensus Statement, we summarize the strengths and weaknesses as well as the future technological potential of each imaging modality.


          Cardiac imaging has a pivotal role in the prevention, diagnosis and treatment of ischaemic heart disease. In this Consensus Statement, the authors summarize the use of SPECT, PET, MRI, echocardiography, CT and invasive coronary flow and pressure measurement, and describe the relative strengths and weaknesses of each modality.

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          Most cited references 158

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          Use of the Instantaneous Wave-free Ratio or Fractional Flow Reserve in PCI.

          Coronary revascularization guided by fractional flow reserve (FFR) is associated with better patient outcomes after the procedure than revascularization guided by angiography alone. It is unknown whether the instantaneous wave-free ratio (iFR), an alternative measure that does not require the administration of adenosine, will offer benefits similar to those of FFR.
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            Coronary microvascular dysfunction: mechanisms and functional assessment.

            Obstructive disease of the epicardial coronary arteries was recognized as the cause of angina pectoris >2 centuries ago, and sudden thrombotic occlusion of an epicardial coronary artery has been established as the cause of acute myocardial infarction for >100 years. In the past 2 decades, dysfunction of the coronary microvasculature emerged as an additional mechanism of myocardial ischaemia that bears important prognostic implications. The coronary microvasculature (vessels <300 μm in diameter) cannot be directly imaged in vivo, but a number of invasive and noninvasive techniques, each with relative advantages and pitfalls, can be used to assess parameters that depend directly on coronary microvascular function. These methods include invasive or noninvasive measurement of Doppler-derived coronary blood flow velocity reserve, assessment of myocardial blood flow and flow reserve using noninvasive imaging, and calculation of microcirculatory resistance indexes during coronary catheterization. These advanced techniques for assessment of the coronary microvasculature have provided novel insights into the pathophysiological role of coronary microvascular dysfunction in the development of myocardial ischaemia in different clinical conditions.
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              Fractional flow reserve versus angiography for guidance of PCI in patients with multivessel coronary artery disease (FAME): 5-year follow-up of a randomised controlled trial.

              In the Fractional Flow Reserve Versus Angiography for Multivessel Evaluation (FAME) study, fractional flow reserve (FFR)-guided percutaneous coronary intervention (PCI) improved outcome compared with angiography-guided PCI for up to 2 years of follow-up. The aim in this study was to investigate whether the favourable clinical outcome with the FFR-guided PCI in the FAME study persisted over a 5-year follow-up.

                Author and article information

                Nat Rev Cardiol
                Nat Rev Cardiol
                Nature Reviews. Cardiology
                Nature Publishing Group UK (London )
                24 February 2020
                24 February 2020
                : 17
                : 7
                : 427-450
                [1 ]ISNI 0000 0001 2218 4662, GRID grid.6363.0, Department of Radiology, , Charité – Universitätsmedizin Berlin, ; Berlin, Germany
                [2 ]GRID grid.484013.a, Berlin Institute of Health and DZHK (German Centre for Cardiovascular Research) Partner Site, ; Berlin, Germany
                [3 ]Department of Biomedical Engineering and Physics – Translational Physiology, Amsterdam University Medical Center, Amsterdam, Netherlands
                [4 ]ISNI 0000 0004 0492 0584, GRID grid.7497.d, Division of X-Ray Imaging and CT, , German Cancer Research Centre (DKFZ), ; Heidelberg, Germany
                [5 ]ISNI 0000 0001 0674 042X, GRID grid.5254.6, The Heart Centre Rigshospitalet, Department of Cardiology and Radiology, , University of Copenhagen, ; Copenhagen, Denmark
                [6 ]ISNI 0000 0001 0942 9821, GRID grid.11804.3c, MTA-SE Cardiovascular Imaging Research Group, Heart and Vascular Center, , Semmelweis University, ; Budapest, Hungary
                [7 ]ISNI 0000 0001 0196 8249, GRID grid.411544.1, Universitätsklinikum Tübingen, Radiologische Klinik, Diagnostische und Interventionelle Radiologie, ; Tübingen, Germany
                [8 ]ISNI 0000 0001 2113 8111, GRID grid.7445.2, Biomedical Image Analysis Group, Department of Computing, , Imperial College London, ; London, UK
                [9 ]Institute of Diagnostic and Interventional Radiology and Department of Cardiology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
                [10 ]ISNI 0000 0001 2156 2780, GRID grid.5801.c, Institute for Biomedical Engineering, , University and ETH Zurich, ; Zurich, Switzerland
                [11 ]ISNI 0000 0001 2322 6764, GRID grid.13097.3c, Department of Cardiovascular Imaging, School of Biomedical Engineering and Imaging Sciences, , King’s College London, ; London, UK
                [12 ]ISNI 0000 0001 2186 1887, GRID grid.4764.1, Physikalisch-Technische Bundesanstalt, Medical Physics and Metrological Information Technologies, ; Berlin, Germany
                [13 ]ISNI 0000 0000 9529 9877, GRID grid.10423.34, Klinik für Nuklearmedizin, Medizinische Hochschule Hannover, ; Hannover, Germany
                [14 ]ISNI 0000 0004 0477 2438, GRID grid.15474.33, Nuklearmedizinische Klinik und Poliklinik, Klinikum rechts der Isar der TU München, DZHK (German Centre for Cardiovascular Research), Partner Site Munich Heart Alliance, ; Munich, Germany
                [15 ]ISNI 0000 0004 0435 165X, GRID grid.16872.3a, Department of Cardiology, , VU University Medical Center, ; Amsterdam, Netherlands
                [16 ]ISNI 0000 0004 1936 9457, GRID grid.8993.b, Department of Surgical Sciences – Nuclear Medicine & PET, , Uppsala University, ; Uppsala, Sweden
                [17 ]ISNI 0000 0001 2351 3333, GRID grid.412354.5, Medical Physics, , Uppsala University Hospital, ; Uppsala, Sweden
                [18 ]ISNI 0000 0001 1114 4366, GRID grid.439338.6, Department of Cardiology, , Royal Brompton Hospital London, ; London, UK
                [19 ]ISNI 0000 0001 2113 8111, GRID grid.7445.2, Department of Bioengineering, , Imperial College London, ; London, UK
                [20 ]Heart Center, Amsterdam University Medical Center, Amsterdam, Netherlands
                [21 ]ISNI 0000 0001 1958 8658, GRID grid.8379.5, Department of Cellular and Molecular Imaging, Comprehensive Heart Failure Center, , Würzburg University Clinics, ; Würzburg, Germany
                © The Author(s) 2020

                Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons license, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons license and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this license, visit http://creativecommons.org/licenses/by/4.0/.

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