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Comparative Study
. 2016 Jul;17(7):779-87.
doi: 10.1093/ehjci/jev206. Epub 2015 Sep 4.

Endocardial-epicardial distribution of myocardial perfusion reserve assessed by multidetector computed tomography in symptomatic patients without significant coronary artery disease: insights from the CORE320 multicentre study

Jørgen Tobias Kühl  1 , Richard T George  2 , Vishal C Mehra  3 , Jesper J Linde  4 , Marcus Chen  5 , Andrew E Arai  5 , Marcelo Di Carli  6 , Kakuya Kitagawa  7 , Marc Dewey  8 , Joao A C Lima  2 , Klaus Fuglsang Kofoed  9
Affiliations
Comparative Study

Endocardial-epicardial distribution of myocardial perfusion reserve assessed by multidetector computed tomography in symptomatic patients without significant coronary artery disease: insights from the CORE320 multicentre study

Jørgen Tobias Kühl et al. Eur Heart J Cardiovasc Imaging. 2016 Jul.

Abstract

Aim: Previous animal studies have demonstrated differences in perfusion and perfusion reserve between the subendocardium and subepicardium. 320-row computed tomography (CT) with sub-millimetre spatial resolution allows for the assessment of transmural differences in myocardial perfusion reserve (MPR) in humans. We aimed to test the hypothesis that MPR in all myocardial layers is determined by age, gender, and cardiovascular risk profile in patients with ischaemic symptoms or equivalent but without obstructive coronary artery disease (CAD).

Methods and results: A total of 149 patients enrolled in the CORE320 study with symptoms or signs of myocardial ischaemia and absence of significant CAD by invasive coronary angiography were scanned with static rest and stress CT perfusion. Myocardial attenuation densities were assessed at rest and during adenosine stress, segmented into 3 myocardial layers and 13 segments. MPR was higher in the subepicardium compared with the subendocardium (124% interquartile range [45, 235] vs. 68% [22,102], P < 0.001). Moreover, MPR in the septum was lower than in the inferolateral and anterolateral segments of the myocardium (55% [19, 104] vs. 89% [37, 168] and 124% [54, 270], P < 0.001). By multivariate analysis, high body mass index was significantly associated with reduced MPR in all myocardial layers when adjusted for cardiovascular risk factors (P = 0.02).

Conclusion: In symptomatic patients without significant coronary artery stenosis, distinct differences in endocardial-epicardial distribution of perfusion reserve may be demonstrated with static CT perfusion. Low MPR in all myocardial layers was observed specifically in obese patients.

Keywords: coronary artery disease; multi-detector computed tomography; myocardial perfusion.

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Figures

Figure 1
Figure 1
Attenuation density (AD) was measured in 3 myocardial layers (endo-, mid-, and epi-) and 13 segments during rest (A: ADRest) and during adenosine stress (B: ADStres). From these measurements regional and global MPR was calculated using the given formula. A difference in endo- to epi-perfusion reserve is noted during adenosine with markedly higher perfusion in the epi layer (B: yellow arrow).
Figure 2
Figure 2
Bar diagram of the difference in MPR between the myocardial layers. Results presented in median and interquartile range.
Figure 3
Figure 3
Regional MPR in the LV septum, anterolateral, and inferolateral myocardium. For transmural myocardial values and each myocardial layer. Septum vs. anterolateral, septum vs. inferolateral, and anterolateral vs. inferolateral were all significantly different (P < 0.05).
Figure 4
Figure 4
Differences between patients with and without abnormal SPECT, showing median values of myocardial attenuation at rest (ADRest) and during pharmacological vasodilation (ADStress) and MPR (in %).
Figure 5
Figure 5
Differences between body mass index groups for median values of myocardial attenuation at rest (ADRest) and during pharmacological vasodilation (ADStress) in baseline-corrected Hounsfield Unit values. Differences between BMI groups for median MPRare in %. *P ≤ 0.01 between normal weight and obesity.
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