Introduction to Noninvasive Cardiac Imaging
2012; Lippincott Williams & Wilkins; Volume: 125; Issue: 3 Linguagem: Inglês
10.1161/circulationaha.110.017665
ISSN1524-4539
Autores Tópico(s)Advanced X-ray and CT Imaging
ResumoHomeCirculationVol. 125, No. 3Introduction to Noninvasive Cardiac Imaging Free AccessBrief ReportPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessBrief ReportPDF/EPUBIntroduction to Noninvasive Cardiac Imaging Ron Blankstein, MD Ron BlanksteinRon Blankstein From the Noninvasive Cardiovascular Imaging Program, Departments of Medicine (Cardiovascular Division) and Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA. Originally published24 Jan 2012https://doi.org/10.1161/CIRCULATIONAHA.110.017665Circulation. 2012;125:e267–e271Noninvasive cardiac imaging refers to a combination of methods that can be used to obtain images related to the structure and function of the heart. As opposed to invasive techniques, which require catheters to be inserted into the heart, noninvasive tests are easier to perform, are safe, and can be used to detect various heart conditions, ranging from plaque in the arteries that supply the heart muscle (known as coronary artery disease) to abnormalities that impair the ability of the heart to pump blood.As a result of technological advances, the number of available noninvasive cardiac tests that physicians can order has increased substantially over the last decade (the Figure). Although these tests have improved physicians' abilities to diagnose and treat heart disease, it is important to understand that not all individuals benefit from noninvasive cardiac imaging. Therefore, these tests should be ordered only at the advice of a physician and should be considered only if the information provided would influence subsequent treatment with medications, procedures, or lifestyle interventions.Download figureDownload PowerPointFigure. Example of images/data typically provided by various noninvasive cardiac tests. CT indicates computed tomography; MRI, magnetic resonance imaging.When Is Noninvasive Cardiac Imaging Used?The goal of cardiac testing may include any of the following: (1) to identify or exclude various forms of heart disease as a reason for a person's symptoms, (2) to establish the risk of developing future heart disease such as a heart attack, and (3) to decide on the need for additional medical therapies and procedures. For instance, in patients with coronary artery disease, the results of imaging tests could be used for selecting between procedures such as placing stents in the arteries of the heart or performing bypass surgery versus pursuing aggressive treatment with medications.Do I Need a Cardiac Imaging Test?Although some cardiac imaging tests can be used to evaluate the risk of individuals who do not have any symptoms, the majority of tests are performed to evaluate the cause of symptoms that may be attributable to cardiovascular disease (Table 1). It is important to know that although some individuals with narrowing in the coronary arteries may experience chest discomfort or shortness of breath—most often during physical activity—such symptoms can be caused by other reasons that are not related to heart disease. Table 2 lists questions about cardiac imaging tests that you should discuss with your physician.Table 1. Symptoms That May Require TestingChest discomfortJaw, left shoulder, or left arm painShortness of breathLightheadedness/dizzinessFatigueTable 2. Questions to Discuss With Your PhysicianWhat is the procedure that I will be having?Do I need this test?Do I have any alternatives?Could the results of this test affect how I am being treated?Will I be required to exercise during this test?Are there any medications which I should stop taking before the test?What Are the Different Types of Cardiac Imaging Tests Available?Table 3 provides an overview of the available noninvasive cardiac tests that your physician may order. Although different types of tests may be used to evaluate different disorders, several different testing options may be suitable for evaluating the same condition. Therefore, if testing is needed, it is important for your doctor to choose the test that she or he feels is the most appropriate for your clinical condition.Table 3. Overview of Noninvasive Cardiac Imaging TestsType of Cardiac TestingWhat Does This Test Show?This Test Is Not Recommended forWhat Are the Most Common Conditions That This Test Evaluates?Patient Preparation/ConsiderationsEchocardiogram(during rest conditions)An ultrasound of the heart is performed by trained technicians and allows doctors to evaluate the pumping function of the heart and the function of the heart valves. Doctors can learn information about the size of the chambers, the thickness of the heart muscle, and whether there is fluid around the lining of the heartEvaluation of coronary artery disease (the arteries of the heart are not seen during this test)Reduced heart pumping function or heart failureNo preparation is requiredDamage after a heart attackThis test is widely availableDisease involving the heart valvesExercise treadmill testing (without imaging)An exercise treadmill testing is performed by an exercise physiologist and provides doctors with information regarding the heart rate, blood pressure, symptoms, and electrocardiogram changes (ie, electric activity of the heart) that occur during or after exercise. This information may be used to identify the likelihood of plaques that limit the blood flow to the heart muscle during exerciseIndividuals who are unable to walk on a treadmillSymptoms with possible cardiac explanationWear comfortable clothes/shoes to exerciseIndividuals who do not have any symptomsThis test is widely availableIndividuals with pacemakers or who have certain ECG abnormalitiesAvoid eating before testThis test will not identify the presence of small plaques that do not limit blood flowCoronary artery calcium scoring scanA calcium scan is a computed tomography of the heart that detects whether there are plaques that contain calcium involving the arteries of the heart. This test does not use any intravenous contrastNot useful for individuals with known coronary artery disease or who are already at high riskDetermine future risk of cardiovascular disease among individuals who have no symptomsNo preparation is requiredIn selected individuals without known coronary artery disease, the presence/amount of plaque can be used to determine future risk of cardiovascular events such as heart attacksNot performed for the evaluation of symptomsUseful only if the results of the test could influence treatment decisionsYou will need to hold your breath for <10 sNot recommended for individuals 75 y of age, and/or the presence of multiple risk factors such as high blood pressure, diabetes mellitus, elevated cholesterol, or smoking)Evaluation of bypass grafts in patients with prior cardiac surgeryYou should not have this test if you are pregnant or are allergic to intravenous contrast dyeEvaluation of narrowing inside coronary stents (except for very large stents)Evaluation before ablation proceduresIndividuals with fast or irregular heart rateIndividuals who have abnormal kidney functionCardiac magnetic resonance imagingA cardiac magnetic resonance imaging test can be used to evaluate for many forms of heart disease, including heart muscle dysfunction, cardiac masses, and many other rare cardiac disorders. During a cardiac magnetic resonance imaging, a stress test (using medications) can be performed by imaging the blood flow to the heart under rest and stress conditionsPatients with certain implanted metallic objects (most pacemakers, all defibrillators) cannot undergo magnetic resonance imagingSymptoms with possible cardiac explanation (see Table 1)If you have severe claustrophobia, this test may not be possible (Although in some cases, use of medications to relax you may help)Patients with severe kidney function abnormalities may not be able to receive gadolinium (special contrast used during most cardiac magnetic resonance imaging examinations)Cause of heart muscle disease (cardiomyopathy)If a stress test will be performed, avoid products containing caffeine for 24 h before the testEvaluation after heart attackThis examination has limited availability and is performed only in specialized centersEvaluation before ablation proceduresCoronary artery disease means deposition of plaques in the arteries that supply the heart muscle with blood. Patients with prior heart attacks, bypass surgery, or stents are all considered to have coronary artery disease.How Will My Physician Choose Among These Tests?The choice of test type will depend on the type of heart disease being evaluated and your medical history. For instance, individuals who already have known coronary artery disease may require a test that identifies abnormalities in blood flow under rest and stress conditions. On the other hand, in lower-risk patients, exercise treadmill testing or cardiac computed tomography can be considered (see Table 3 for details). Because not all tests are available in all centers and different facilities may have different areas of expertise, your doctor should choose a test that your local hospital or clinic has sufficient experience in performing and interpreting.Most computed tomography examinations and some magnetic resonance imaging examinations require the use of intravenous contrast administration. Use of such contrast should be avoided in patients with abnormal kidney function (If needed, kidney function can be determined with a blood test). Furthermore, patients who are overweight may have lower image quality for some types of tests (stress echocardiogram, nuclear single-photon emission computed tomography) and may benefit from alternative techniques (eg, cardiac magnetic resonance imaging, nuclear positron emission tomography) if available.What Are the Risks of Testing?The majority of cardiac imaging tests are extremely safe. During tests that use exercise or medications that simulate the effects of exercise, the chance of having a heart attack or dying as a result of the test is less than 1 in 10 000.Tests that use a radioactive medication (nuclear cardiology) or x-rays (computed tomography) are associated with a small exposure to radiation. Table 4 provides a comparison of the radiation dose of commonly used cardiac imaging tests relative to nonmedical exposure from background radiation. Although there is no direct evidence linking the small amounts of radiation used in imaging tests to the development of cancer, given the known harmful effects of larger amounts of radiation, it is prudent to limit unnecessary exposure to radiation, particularly in younger individuals because they may be more susceptible to the potential harmful effects of radiation.Table 4. Typical Radiation Exposure Associated With Cardiac Imaging Tests Relative to Naturally Occurring Background Radiation ExposureTest TypeExposure(Relative to Row 1)Naturally occurring annual background radiation exposure for a person living in the United States (≈3 mSv)1Coronary artery calcium score0.5Cardiac computed tomography angiography1–4Nuclear stress test (single-photon emission computed tomography)13–4Exercise treadmill testing (with no imaging)0Cardiac magnetic resonance imaging/echocardiogram0Note that the above estimates are based on typical estimates using the most commonly performed techniques; actual exposure may vary between individuals and among different centers.It is important to understand that for the majority of patients who require cardiovascular testing, the benefit of these tests far outweighs the small amount of risk. If you have questions about the benefits and risks of the examination, it is always best to talk with your doctor. Before your test, technicians and/or physicians specializing in imaging may also be able to provide you with more information about your specific test.AcknowledgmentThe author acknowledges Erin West, chief exercise physiologist, Brigham and Women's Hospital.DisclosuresNone.FootnotesThe information contained in this Circulation Cardiology Patient Page is not a substitute for medical advice, and the American Heart Association recommends consultation with your doctor or healthcare professional.Correspondence to Ron Blankstein, MD, FACC, Noninvasive Cardiovascular Imaging Program, Department of Medicine (Cardiovascular Division) and Department of Radiology, Brigham and Women's Hospital, 75 Francis St, Room Shapiro 5096, Boston, MA 02115. E-mail [email protected]orgReference1. Fazel R, Dilsizian V, Einstein AJ, Ficaro EP, Henzlova M, Shaw LJ. Strategies for defining an optimal risk-benefit ratio for stress myocardial perfusion spect. 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