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Myocardial Ischemia
Jacob Blackwell, MD; Paige Bennett, MD
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KEY FACTS

  • Terminology

    • Diagnostic Checklist

      TERMINOLOGY

      • Definitions

        • Myocardial ischemia is caused by limited perfusion of coronary arteries, which lowers myocardial blood supply
          • Vascular stenosis is due to monocyte/lymphocyte inflammatory response to damaged endothelium with oxidized LDL deposition, foam cell formation, and vascular calcification
          • Rupture of stenotic plaque can cause abrupt worsening of ischemia
        • Arteries supplying left ventricle of heart
          • Left anterior descending (LAD) artery supplies anterior/septal wall
            • Apex usually supplied from LAD, but variable
          • Circumflex artery supplies lateral wall
          • Posterior descending artery (PDA) supplies inferior wall
            • Right coronary artery (RCA) in 85% (right dominant)
            • Continuation of circumflex in 15% (left dominant)

      IMAGING

      • PET/CT Myocardial Perfusion Imaging Findings

        • Artifacts and Quality Control

          DIFFERENTIAL DIAGNOSIS

            PATHOLOGY

            • General Features

              CLINICAL ISSUES

              • Presentation

                • Demographics

                  • Natural History & Prognosis

                    • Treatment

                      DIAGNOSTIC CHECKLIST

                      • Reporting Tips

                        Selected References

                        1. Driessen RS et al: Myocardial perfusion imaging with PET. Int J Cardiovasc Imaging. ePub, 2017
                        2. Schindler TH: Myocardial blood flow: Putting it into clinical perspective. J Nucl Cardiol. 23(5):1056-71, 2016
                        3. Takx RA et al: Diagnostic accuracy of stress myocardial perfusion imaging compared to invasive coronary angiography with fractional flow reserve meta-analysis. Circ Cardiovasc Imaging. 8(1), 2015
                        4. Travin MI: Pitfalls and limitations of radionuclide and hybrid cardiac imaging. Semin Nucl Med. 45(5):392-410, 2015
                        5. Dorbala S et al: SNMMI/ASNC/SCCT guideline for cardiac SPECT/CT and PET/CT 1.0. J Nucl Med. 54(8):1485-507, 2013
                        6. De Bruyne B et al: Fractional flow reserve-guided PCI versus medical therapy in stable coronary disease. N Engl J Med. 367(11):991-1001, 2012
                        7. Rischpler C et al: Transient ischemic dilation ratio in 82Rb PET myocardial perfusion imaging: normal values and significance as a diagnostic and prognostic marker. J Nucl Med. 53(5):723-30, 2012
                        8. Weintraub WS et al: Comparative effectiveness of revascularization strategies. N Engl J Med. 366(16):1467-76, 2012
                        9. Maddahi J et al: Phase I, first-in-human study of BMS747158, a novel 18F-labeled tracer for myocardial perfusion PET: dosimetry, biodistribution, safety, and imaging characteristics after a single injection at rest. J Nucl Med. 52(9):1490-8, 2011
                        10. Bravo PE et al: Reference ranges for LVEF and LV volumes from electrocardiographically gated 82Rb cardiac PET/CT using commercially available software. J Nucl Med. 51(6):898-905, 2010
                        11. Boden WE et al: Optimal medical therapy with or without PCI for stable coronary disease. N Engl J Med. 356(15):1503-16, 2007
                        12. Cannon CP et al: Comparison of early invasive and conservative strategies in patients with unstable coronary syndromes treated with the glycoprotein IIb/IIIa inhibitor tirofiban. N Engl J Med. 344(25):1879-87, 2001
                        13. Struass HW et al: SNM Procedure Guideline for Myocardial Perfusion Imaging 3.3. J Nucl Med Technol. 36(3)155-61, 2008
                        14. Dorbala S et al: Prognostic Value of Stress Myocardial Perfusion Positron Emission Tomography: Results From A Multicenter Observational Registry. J Am Coll Cardiol. 61(2):176-84, 2013
                        15. Murthy VL et al: Improved Cardiac Risk Assessment with Non-Invasive measures of Coronary flow reserve. Circulation. 124:2215–2224, 2011
                        16. Dilsizian V et al: PET myocardial perfusion and metabolism clinical imaging. ASNC imaging guidelines for nuclear cardiology procedures. Journal of Nuclear Cardiology. 2009
                        17. Loghin C et al: Common Artifacts in PET Myocardial Perfusion Images Due to Attenuation–Emission Misregistration: Clinical Significance, Causes, and Solutions. J Nucl Med. 45(6):1029-1039, 2004
                        Related Anatomy
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                        Related Differential Diagnoses
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                        References
                        Tables

                        Tables

                        KEY FACTS

                        • Terminology

                          • Diagnostic Checklist

                            TERMINOLOGY

                            • Definitions

                              • Myocardial ischemia is caused by limited perfusion of coronary arteries, which lowers myocardial blood supply
                                • Vascular stenosis is due to monocyte/lymphocyte inflammatory response to damaged endothelium with oxidized LDL deposition, foam cell formation, and vascular calcification
                                • Rupture of stenotic plaque can cause abrupt worsening of ischemia
                              • Arteries supplying left ventricle of heart
                                • Left anterior descending (LAD) artery supplies anterior/septal wall
                                  • Apex usually supplied from LAD, but variable
                                • Circumflex artery supplies lateral wall
                                • Posterior descending artery (PDA) supplies inferior wall
                                  • Right coronary artery (RCA) in 85% (right dominant)
                                  • Continuation of circumflex in 15% (left dominant)

                            IMAGING

                            • PET/CT Myocardial Perfusion Imaging Findings

                              • Artifacts and Quality Control

                                DIFFERENTIAL DIAGNOSIS

                                  PATHOLOGY

                                  • General Features

                                    CLINICAL ISSUES

                                    • Presentation

                                      • Demographics

                                        • Natural History & Prognosis

                                          • Treatment

                                            DIAGNOSTIC CHECKLIST

                                            • Reporting Tips

                                              Selected References

                                              1. Driessen RS et al: Myocardial perfusion imaging with PET. Int J Cardiovasc Imaging. ePub, 2017
                                              2. Schindler TH: Myocardial blood flow: Putting it into clinical perspective. J Nucl Cardiol. 23(5):1056-71, 2016
                                              3. Takx RA et al: Diagnostic accuracy of stress myocardial perfusion imaging compared to invasive coronary angiography with fractional flow reserve meta-analysis. Circ Cardiovasc Imaging. 8(1), 2015
                                              4. Travin MI: Pitfalls and limitations of radionuclide and hybrid cardiac imaging. Semin Nucl Med. 45(5):392-410, 2015
                                              5. Dorbala S et al: SNMMI/ASNC/SCCT guideline for cardiac SPECT/CT and PET/CT 1.0. J Nucl Med. 54(8):1485-507, 2013
                                              6. De Bruyne B et al: Fractional flow reserve-guided PCI versus medical therapy in stable coronary disease. N Engl J Med. 367(11):991-1001, 2012
                                              7. Rischpler C et al: Transient ischemic dilation ratio in 82Rb PET myocardial perfusion imaging: normal values and significance as a diagnostic and prognostic marker. J Nucl Med. 53(5):723-30, 2012
                                              8. Weintraub WS et al: Comparative effectiveness of revascularization strategies. N Engl J Med. 366(16):1467-76, 2012
                                              9. Maddahi J et al: Phase I, first-in-human study of BMS747158, a novel 18F-labeled tracer for myocardial perfusion PET: dosimetry, biodistribution, safety, and imaging characteristics after a single injection at rest. J Nucl Med. 52(9):1490-8, 2011
                                              10. Bravo PE et al: Reference ranges for LVEF and LV volumes from electrocardiographically gated 82Rb cardiac PET/CT using commercially available software. J Nucl Med. 51(6):898-905, 2010
                                              11. Boden WE et al: Optimal medical therapy with or without PCI for stable coronary disease. N Engl J Med. 356(15):1503-16, 2007
                                              12. Cannon CP et al: Comparison of early invasive and conservative strategies in patients with unstable coronary syndromes treated with the glycoprotein IIb/IIIa inhibitor tirofiban. N Engl J Med. 344(25):1879-87, 2001
                                              13. Struass HW et al: SNM Procedure Guideline for Myocardial Perfusion Imaging 3.3. J Nucl Med Technol. 36(3)155-61, 2008
                                              14. Dorbala S et al: Prognostic Value of Stress Myocardial Perfusion Positron Emission Tomography: Results From A Multicenter Observational Registry. J Am Coll Cardiol. 61(2):176-84, 2013
                                              15. Murthy VL et al: Improved Cardiac Risk Assessment with Non-Invasive measures of Coronary flow reserve. Circulation. 124:2215–2224, 2011
                                              16. Dilsizian V et al: PET myocardial perfusion and metabolism clinical imaging. ASNC imaging guidelines for nuclear cardiology procedures. Journal of Nuclear Cardiology. 2009
                                              17. Loghin C et al: Common Artifacts in PET Myocardial Perfusion Images Due to Attenuation–Emission Misregistration: Clinical Significance, Causes, and Solutions. J Nucl Med. 45(6):1029-1039, 2004