In recent years, modern imaging tests have replaced exercise treadmill testing to diagnose coronary artery disease, with single-photon emission computed tomography (SPECT) being the most common, although accuracy varies and patients are exposed to ionising radiation. But a study published Online First by the Lancet shows that a more modern method— multiparametric cardiovascular magnetic resonance (CMR)—is superior to SPECT and should be more widely adopted. The Article is by Dr John Greenwood, University of Leeds, UK and Leeds General Infirmary, UK and colleagues.
All non-invasive imaging tests have their limitations. For SPECT this includes patient and staff exposure to ionizing radiation and limited spatial resolution of the images. For CMR, the test takes a little longer and some patients who are claustrophobic or have implanted devices (e.g. pacemakers) are not suitable. However, CMR is considered very safe and is becoming more widely available.
In this prospective trial, patients with suspected angina pectoris and at least one cardiovascular risk factor were scheduled for CMR, SPECT, and invasive x-ray coronary angiography. Of the 752 recruited patients, 39% had significant CHD as identified by x-ray angiography. For multiparametric CMR the sensitivity* was 87%, specificity 83%, positive predictive value 77%, and negative predictive value 90%. The sensitivity of SPECT was 66%, specificity 83%, positive predictive value 71%, and negative predictive value 79%. The sensitivity and negative predictive value of CMR and SPECT differed significantly statistically but specificity and positive predictive value did not.
The authors say that the study shows CMR should be included in all evidence-based clinical management guidelines. They conclude: "CE-MARC is the largest, prospective, real world assessment of CMR. The findings of CE-MARC support the wider adoption of CMR for the diagnosis and management of stable coronary heart disease patients, in view of the growing concern of the cancer risk associated with medical-source ionising radiation."
In a linked Comment, Dr Robert O Bonow, Center for Cardiovascular Innovation, Northwestern University Feinberg School of Medicine, Chicago, IL, USA, says: "Enhanced diagnostic accuracy of CMR must be balanced against availability and cost-effectiveness, and there is a need for evidence of measurable improvements in patient outcomes."
He concludes: "The explosive growth of cardiovascular technology in the second half of the 20th century coincided with a remarkable decrease in coronary mortality in the same period. However, whether diagnostic imaging had a role in these improved outcomes is unclear. What is clear is that use of imaging has increased more rapidly than any other component of medical care. Research is now sorely needed to show that the appropriate use of these resources can further improve patient outcomes."
Dr John Greenwood, Department of Cardiology, Leeds General Infirmary, UK, and University of Leeds, UK. T) 44-113-3925404 E) j.greenwood@leeds.ac.uk
Dr Robert O Bonow, Center for Cardiovascular Innovation, Northwestern University Feinberg School of Medicine, Chicago, IL, USA. T) 312-695-1105 E) r-bonow@northwestern.edu
Notes to editors: *Sensitivity: the proportion of actual positives which are correctly identified as such.
Specificity: the proportion of negatives which are correctly identified.
Positive predictive value: the proportion of subjects with positive test results who are correctly diagnosed.
Negative predictive value: proportion of subjects with a negative test result who are correctly diagnosed.
Journal
The Lancet