USE OF CARDIAC MAGNETIC

RESONANCE IMAGING AND

POSITRON EMISSION
TOMOGRAPHY IN ASSESSMENT OF
CARDIOVASCULAR DISEASE RISK
AND ATHEROSCLEROSIS
PROGRESSION
Prabhakar Rajiah and Milind Y. Desai
Preventive Cardiology Companion to Braunwalds Heart Disease Chapter 28

Presented by :
Natalia Wara, MD
Introduction
■ Atherosclerosis  a diffuse, chronic immunoinflammatory disease of the
vascular, metabolic, and immune systems characterized by deposition of lipid
and fibrous products in the arterial wall  the single most important
contributor to the burden of cardiovascular disease.
■ Conventionally, imaging has focused on detection and grading of stenotic
lesions and perfusion abnormalities in organs distal to the stenosis.
■ However, major acute events (MI or CVD) are generally produced not by
plaques with high-grade stenosis but by disruption of vulnerable plaques
■ Hence, there is a need for new diagnostic tests that will be able to detect,
quantify, and characterize the plaque so that high-risk patients can be
identified and treatment initiated earlier in the long asymptomatic phase to
modify the disease progression and to reduce the risk of a major event.
 Imaging of Atherosclerosis
■ The purposes of imaging in atherosclerosis :
– understanding of the natural history and pathobiology of atherosclerosis
– diagnosis of subclinical disease and risk stratification
– evaluation of plaque burden (location, size, chemical composition, biologic
activity)
– identification of vulnerable plaque.
■ The various available imaging options include
– invasive techniques : coronary angiography, intravascular ultrasound,
palpography, and optical coherence tomography,
– Non invasive techniques : high-resolution ultrasound, computed tomography (CT),
single-photon emission computed tomography (SPECT), positron emission
tomography (PET), and magnetic resonance imaging (MRI)
 Imaging of Atherosclerosis
■ The ideal imaging technique should be sufficiently sensitive and specific for
detection of atherosclerosis, inexpensive, reproducible, easy to perform, widely
available, tolerated by patients, and non invasive or minimally invasive, should
have no or minimal radiation, provide immediate results, quantify plaque
components, be feasible in all vascular beds, add predictive value over
measurement of established risk factors, and correlate highly with risks of
subsequent major events
 Magnetic Resonance Imaging (MRI)
■ MRI uses the magnetic characteristics of the most abundant proton in the
human body, hydrogen, to generate images. The combination of radiofrequency
and gradient waveforms used to obtain an image is called a pulse sequence. The
appearance and signal intensity of any tissue on MRI depend on the type of
pulse sequence and imaging parameters.
■ MRI is non invasive and has no ionizing radiation; it has high inherent soft tissue
contrast, spatiotemporal resolution, large field of view, and multiplanar imaging
capabilities. Intravenous chelated gadolinium contrast material is useful for
further characterization, but it is best avoided in patients with severe renal
dysfunction
 Magnetic Resonance Imaging (MRI)
• MRI Technique in CVD :
• High Resolution Multi contrast
Imaging
• Coronary Magnetic Resonance
Angiography
• Magnetic Resonance Angiography
• Peripheral MRI
• Myocardial Function
• Intravascular MRI
• Shear Stress
• Vascular Function
• Molecular Imaging
High Resolution Multi Contrast

■ High Resolution MRI is used to characterize the atherosclerotic plaque

■ MRI has high inherent soft tissue contrast that is ideal for
characterization and differentiation of plaque components
■ High-resolution MRI with multi contrast black blood techniques and
dynamic contrast-enhanced angiography is used to characterize the
specific tissue components of complex plaques, which aids in the
detection of vulnerable plaque.
■ The MRI findings have been validated in histologic studies and are highly
reproducible both qualitatively and quantitatively, thus making MRI
useful for serial evaluation of plaque progression or regression.
High Resolution Multi Contrast
 High Resonance Multi Contrast

Plaque can be measured manually or by automated

techniques such as MEPPS and CASCADE which are
based on probabilistic assumptions.
Magnetic Resonance Angiography

■ Coronary MRA provides information on the coronary artery lumen and

vessel wall including plaque, without radiation or intravenous
administration of contrast material. However, valuation of coronary
arteries requires high spatial resolution (3 to 4 mm) and temporal
resolution (<75 msec).
■ MRI has a sensitivity of 80% to 90%, specificity of >90%, and negative
predictive value of 81% for identification of coronary artery stenosis.
 Magnetic Resonance Angiography
■ Whole-body MRA can examine the entire
arterial tree excluding the intracranial and
coronary vessels in one sitting by use of
bolus chase technique, multichannel
receiver surface coils, and parallel imaging
techniques, without radiation or arterial
cannulation, and it is less nephrotoxic.
■ The ability to image multiple vascular beds
makes it useful in evaluation of
atherosclerosis.
 Myocardial Function
■ MRI is the most accurate technique in the
evaluation of cardiac volumes and mass,
with only 5% standard errors compared
with 20% for echocardiography.
■ Radial, circumferential, and longitudinal
strains can be measured on MRI by
myocardial tagging techniques, such as
SPAMM (spatial modulation of
magnetization) or CSPAMM
(complementary spatial modulation of
magnetization), which pro- duces dark
saturation bands perpendicular to the
scanning plane
Myocardial Function
■ A direct relationship between regional diastolic dysfunction (decreased
diastolic strain) and increasing left ventricular mass is demonstrated in
asymptomatic individuals.
■ Increased diastolic blood pressure was associated with decreased
circumferential strain in asymptomatic individuals particularly in
smokers.
Stress Perfusion MRI
■ Perfusion MRI is performed both at rest and after pharmacologic stress
(adenosine or dipyridamole)
■ Intravenous contrast produces T1 shortening of normal myocardium,
resulting in bright signal on T1-weighted sequences. But hypo perfused
areas (ischemic or revascularized infarct) appear dark
■ Dobutamine infusion makes ischemic segments dysfunctional, which
could be assessed by cardiac MRI as an alternative test for the diagnosis
of CAD and quantifying myocardium at risk, particularly useful in patients
in whom echocardiography cannot be performed. The sensitivity of
dobutamine MRI is higher than that of echocardiography,
■ Combined adenosine and dobutamine stress imaging showed 99%
survival in patients with normal images and 84% with abnormal images
Positron Emission Tomography (PET)
■ PET is based on beta decay of radioisotopes that results in the emission
of a positron, a positively charged beta particle.  direct evaluation of
the atherosclerotic plaque and also in the assessment of myocardial
ischemia.
■ PET/CT is a type of hybrid imaging that combines the images from PET
and CT scans performed at the same time on the same machine, which
helps in correlation of anatomic and functional information, thereby
improving accuracy and reduces scanning time .
■ PET has also been well established as a useful technique in serial follow-
up for evaluation of plaque for progression or regression
Positron Emission Tomography (PET)
■ PET Imaging of Atherosclerotic Plaque :
– Imaging of Macrophage
– Imaging of Other Macrophage Targets  benzodiazepine receptors in mitochondrial
membranes
– Imaging of Other PET Targets  Proliferating smooth muscle cells in the plaque, lipid
core of atherosclerosis and Annexin V
– VCAM
– RAGE
■ PET is an ideal technique for evaluation of silent or overt ischemia and
assessment of response to various therapies because of its high accuracy
and reliability in quantitative estimation of myocardial blood flow and
perfusion reserve.
Positron Emission Tomography (PET)

■ Evaluation of Ischemia  Coronary Blood Reserve  Increase of myocardial

blood flow from rest to stress  predictor of future cardiovascular outcome in
patients with cardiomyopathies in the absence of CAD
■ PET in Early Stage CAD  Abnormal Myocardial Perfusion Reserve related to
10 year CHD risk in a population with no known CAD but have intermediate
CAD risk and as a significantly worse prognosis in patient with known CAD
■ PET in advanced CVD  identifies patients with moderate to severe ischemia
but with viable myocardium, the subset of patients who will benefit from
revascularization. PET has 93% sensitivity, 58% specificity, and 71% PPV and
86% NPV to detect myocardial viability
Positron Emission Tomography (PET)
Positron Emission Tomography (PET)
Key Points

■ Atherosclerosis is a chronic immunoinflammatory disorder of the

vascular, metabolic, and immune systems.
■ Detection of subclinical atherosclerotic disease will enable initiation
of earlier treatment and prevent the progression of atherosclerotic
vascular disease and plaque disruption.
■ MRI can evaluate various aspects of cardiovascular disease,
including plaque morphology, vascular physiology, and myocardial
function.
Key Points

■ High-resolution multi contrast MRI is used to characterize the

specific tissue components of complex plaques, which aids in the
detection of vulnerable plaque.
■ Because of high reproducibility, MRI is valuable in assessment of
plaque progression and regression.
■ Molecular imaging elucidates the biology of various cellular and
molecular targets in atherosclerosis before the development of gross
phenotypic changes.
Key Points

■ MRI is an ideal molecular imaging modality because of its high

spatial and temporal resolutions, non invasive nature, lack of ionizing
radiation, and excellent reproducibility.
■ PET can assess inflammatory activity within atherosclerotic plaque
because of avid FDG uptake and accumulation within the
macrophages in inflamed plaque.
■ PET can simultaneously evaluate cardiac perfusion and metabolism
and hence plays a vital role in evaluation of selected patients with
cardiovascular risk factors or disease.
 Conclusion
■ MRI and PET are useful imaging techniques in the evaluation of different stages of
atherosclerosis and assessment of cardiovascular risk factors.
■ High-resolution multi contrast MRI is a valuable non invasive technique in plaque
characterization and quantification. MRI is also useful in the evaluation of global and
regional myocardial function, myocardial ischemia, and various vascular factors.
■ Whole-body MRA can be used to evaluate multiple vascular beds in a single
examination, particularly in the asymptomatic intermediate-risk group.
■ PET scanning can be used in targeted imaging of atherosclerosis with molecular
probes and also in the evaluation of myocardial ischemia.
■ Both MRI and PET are useful in the assessment of plaque progression or regression,
particularly as a surrogate endpoint of treatment in response to novel drugs.
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