AJR Integrative Imaging

LIFELONG LEARNING
Attili et al. FOR RADIOLOGY
CT and MRI of Coronary
Artery Disease: Self-Assessment Module
Anil K. Attili1, Jonathan M. Foral2, U. Joseph Schoepf3, Philip N. Cascade1, and Felix S. Chew4

ABSTRACT B. Exercise, self-assess, and improve his or her knowledge of the

The educational objectives for this self-assessment module on
CT and MRI of coronary artery disease are for the participant to
exercise, self-assess, and improve his or her knowledge of the clin-
ical applications of CT and MRI in evaluating coronary artery
disease.
INTRODUCTION
This self-assessment module on CT and MRI of coronary artery
disease has an educational component and a self-assessment com-
ponent. The educational component consists of two required arti-
cles that the participant should read. The self-assessment
component consists of seven multiple-choice questions with solu-
tions. All of these materials are available on the ARRS Web site
American Journal of Roentgenology 2006.187:S500-S504.
clinical application of MRI to diseases of the coronary arteries.
REQUIRED READING
(available at www.arrs.org)
1. Attili AK, Cascade PN. CT and MRI of coronary artery disease:
evidence-based review. AJR 2006; 187[suppl]:S483–S499
2. Schoepf UJ. CT angiography of the coronary arteries. In:
McAdams HP, Reddy GP, eds. Cardiopulmonary imaging: cat-
egorical course syllabus. Leesburg, VA: American Roentgen
Ray Society, 2005:151–160
INSTRUCTIONS
1. Complete the required reading.

2. Visit www.arrs.org and select the Journals/Integrative Imag-

(www.arrs.org). To claim CME and SAM credit, each participant
ing link on the left-hand side of the home page.
must enter his or her responses to the questions online.
3. Using your member login, order the online SAM as directed.
4. Follow the online instructions for entering your responses to
EDUCATIONAL OBJECTIVES the self-assessment questions and complete the test by answer-
By completing this educational activity, the participant will: ing the questions online.
A. Exercise, self-assess, and improve his or her knowledge of the
clinical application of CT to diseases of the coronary arteries.

Keywords: cardiac imaging, coronary artery disease, CT angiography, MDCT, MRI

DOI:10.2214/AJR.06.1191
Received September 6, 2006; accepted without revision September 6, 2006.
1Department of Radiology, University of Michigan, Ann Arbor, MI 48109-0302.
2Department of Radiology, Harborview Medical Center, Seattle, WA 98104.
3Department of Radiology, Center for Advanced Imaging Research, Medical University of South Carolina, Charleston, SC 29425.
4Department of Radiology, University of Washington, Box 354755, 4245 Roosevelt Way NE, Seattle, WA 98105. Address correspondence to F. S. Chew (fchew@u.washington.edu).
AJR 2006; 187:S500–S504 0361–803X/06/1876–S500 © American Roentgen Ray Society

S500 AJR:187, December 2006

 CT and MRI of Coronary Artery Disease
QUESTION 1
Regarding coronary artery anomalies, which
statement is TRUE?
A. Anomalous origin of the right coronary artery from the left
sinus of Valsalva is clinically benign.
B. The stress ECG is highly sensitive in detecting coronary
artery anomalies.
C. Catheter angiography is the imaging technique of choice for
a suspected coronary artery anomaly.
D. Myocardial bridging manifests as fixed narrowing of the
affected coronary artery segment.
E. Anomalous origin of the left coronary artery from the right
sinus of Valsalva is a high-risk lesion for sudden death.
QUESTION 2
Regarding coronary artery aneurysms, which
American Journal of Roentgenology 2006.187:S500-S504.
statement is TRUE?
A. Atherosclerosis is the most common cause worldwide.
B. The left main coronary artery is the most common site of
occurrence.
C. Eighty percent of patients with Kawasaki disease develop
coronary artery aneurysms.
D. Catheter angiography is the gold standard for determining
their true size.
E. Myocardial infarction may be caused by secondary
thromboembolism.
QUESTION 3
After a myocardial infarction, which imaging technique
is most likely to distinguish irreversibly injured myocar-
dium from dysfunctional but viable myocardium?
A. Unenhanced CT for calcium scoring.
B. Enhanced CT with pharmacologic stress.
C. Delayed contrast-enhanced MRI.
D. Echocardiography.
E. Catheter angiography.
QUESTION 4
Regarding the technique of delayed contrast-enhanced
MRI, which of the following statements is TRUE?
A. With delayed enhancement imaging, fibrous tissue actively
takes up gadolinium.
B. Delayed enhancement imaging typically uses a T1-weighted
spin-echo sequence.
AJR:187, December 2006
C. With an appropriate inversion time, the signal intensity of
normal myocardium should be close to null.
D. A 2D sequence results in more motion artifact than a 3D
sequence.
E. IV-injected gadolinium remains in the intravascular space
unless there is capillary leakage.
QUESTION 5
Regarding CT angiography technique, which of
the following is TRUE?
A. Beta-blockers may improve image quality by decreasing a
patient’s heart rate.
B. The right coronary artery is best depicted in images recon-
structed in late or end-diastole.
C. In patients with high calcium scores (> 75th percentile), CT
angiography is accurate for evaluating coronary artery
stenosis.
D. The effective radiation dose from uncomplicated conven-
tional angiography is greater than CT angiography.
E. CT angiography has a higher spatial and temporal resolu-
tion than conventional catheter angiography.
QUESTION 6
When is contrast-enhanced CT angiography of the
coronary arteries NOT indicated?
A. Evaluation of the patency of a coronary artery bypass graft.
B. Noninvasive detection of coronary artery stenosis.
C. Suspected coronary artery anatomic anomalies.
D. Acute myocardial infarction with elevated cardiac enzymes
and diagnostic ECG changes.
E. Pulmonary vein imaging in the context of ablation therapy
for ectopic electrical activity.
QUESTION 7
Regarding coronary CT angiography (CTA) as a
triage tool for acute chest pain in the emergency
department, which statement is TRUE?
A. Single-detector CT is adequate to assess the coronary
arteries in the emergent setting.
B. It is indicated in patients with a high pretest probability of
coronary artery disease.
C. Extending the protocol to include the pulmonary arteries
and the thoracic aorta is an area of current investigation.
D. Negative findings on coronary CTA require conventional
catheter angiography to exclude significant coronary
artery disease.
E. Acute chest pain as a presenting symptom is usually caused
by a coronary syndrome.
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 Attili et al.
Solution to Question 1
Congenital anomalies of the coronary arteries that are associ-
ated with increased risk of myocardial ischemia and sudden
death are classified as malignant; those that are not associated
with such a risk are classified as benign. The most common of the
malignant anomalies is origin of the right coronary artery from
the left sinus of Valsalva. Option A is not the best response.
The stress ECG can be normal in the presence of coronary ar-
tery anomalies and is not considered reliable as a screening test
[1]. Option B is not the best response.
Coronary artery anomalies are often difficult to fully charac-
terize on catheter angiography. Both CT angiography [2] and
MR angiography can identify and characterize anomalous coro-
nary arteries with a higher accuracy than catheter angiography
[3, 4]. Option C is not the best response.
An epicardial segment of a coronary artery that courses
through the myocardium is termed “myocardial bridging.” With
myocardial bridging, the involved coronary artery is compressed
in systole. The clinical significance of myocardial bridges is uncer-
American Journal of Roentgenology 2006.187:S500-S504.
tain, but generally, myocardial bridging is considered a benign con-
dition because most coronary flow occurs during diastole.
However, myocardial bridging has been reported as a cause of an-
gina, ischemia, or infarction [5]. Option D is not the best response.
Sudden death, usually during or shortly after vigorous exertion,
may be the first clinical manifestation in patients with ectopic cor-
onary artery origin, such as an anomalous left coronary artery
arising from the right sinus [6]. However, warning symptoms such
as chest pain and syncope may occur in a substantial proportion
of these individuals. Option E is the best response.
Solution to Question 2
Coronary artery aneurysms are defined as segments of vessels
with a diameter greater than 1.5 times that of the normal adja-
cent artery segment; they can be classified as fusiform or saccu-
lar [7]. Kawasaki disease is the most frequent cause of coronary
aneurysms worldwide, whereas atherosclerotic coronary disease
is the most common cause in the United States. Option A is not
the best response.
The most commonly affected coronary artery segments are, in
order of frequency, the proximal and mid portions of the right
coronary artery, the proximal portion of the left anterior de-
scending artery, and the proximal portion of the circumflex cor-
onary artery. Aneurysms of the left main coronary trunk are
unusual [8]. Option B is not the best response.
Kawasaki disease is an acute vasculitis of infancy and child-
hood. When Kawasaki disease is untreated, only 15–25% of pa-
tients develop coronary artery aneurysms [9]. When the disease
is treated with corticosteroids, the incidence of aneurysms is even
lower. Option C is not the best response.
The true size of an aneurysm may be underestimated on cath-
eter angiography if the aneurysm contains substantial throm-
bus. ECG-gated CT allows more rapid and accurate delineation
S502
of the size and shape of aneurysms [10]. MRI offers an alterna-
tive imaging technique for evaluating coronary artery aneu-
rysms, but the spatial resolution of MRI is inferior to that of CT.
Option D is not the best response.
Myocardial infarction may be caused by thromboembolism
from coronary artery aneurysms. Option E is the best response.
Solution to Question 3
Identification of irreversibly injured myocardium from dys-
functional, but viable and potentially salvageable, myocardium is
of crucial importance for the management of cardiac patients. Re-
vascularization of an infarcted area is justified only if the patient
is likely to benefit from the procedure. Delayed contrast-enhanced
MRI is an excellent tool to evaluate myocardial viability and dif-
ferentiate between patients who are likely to benefit from revascu-
larization and patients who are not likely to benefit [11, 12].
Dysfunctional, predominantly viable segments will have no or
minimal hyperenhancement, whereas predominantly scarred seg-
ments will show extensive hyperenhancement. Dysfunctional seg-
ments with extensive enhancement on delayed contrast-enhanced
MRI are unlikely to exhibit functional recovery after percutane-
ous or surgical revascularization. Option C is the best response.
Calcium scoring has no role in the evaluation of myocardial vi-
ability. Calcium scoring is used as a risk factor for coronary artery
disease. Option A is not the best response.
Enhanced CT with pharmacologic stress, echocardiography,
and catheter angiography may show dysfunctional myocardial
motion, but those techniques do not evaluate myocardial viabil-
ity. Options B, D, and E are not the best responses.
Solution to Question 4
The delayed contrast-enhanced MRI technique for detection
of myocardial viability relies on the extracellular distribution of
gadolinium chelates in the myocardium. In regions with in-
creased extracellular space (e.g., infarction and fibrosis), higher
concentrations of gadolinium accumulate, with concomitant
slower clearance and higher signal on delayed enhancement se-
quences [13]. Option A is not the best response.
The typical pulse sequence for myocardial delayed enhance-
ment is an inversion recovery–prepared segmented gradient-echo
sequence, which exhibits an increased signal intensity of tissue
that is superior to other imaging techniques such as spin-echo
techniques [14]. Option B is not the best response.
“Nulling” of the normal myocardium is critical if areas of hy-
perenhancement are to be properly displayed. The gradient-echo
technique used consists of an inversion prepulse chosen so that
there is no or little longitudinal magnetization in the normal
myocardium. Selection of the appropriate inversion time is cru-
cial. In clinical settings, this is usually performed visually by ap-
plying a 2D inversion sequence with variable prepulse delays
(200–300 milliseconds in steps of 25 milliseconds) or a Look-
Locker sequence. The optimal TI (time to inversion) is the delay
AJR:187, December 2006
 CT and MRI of Coronary Artery Disease
with the best visual suppression of myocardium. The typical sig-
nal intensity is a dark myocardium, a slightly brighter blood
pool, and a very bright infarct. Option C is the best response.
Three-dimensional sequences are subject to more motion artifact
because of the larger number of k-space lines that must be acquired
compared with 2D sequences. Option D is not the best response.
IV-injected gadolinium rapidly diffuses into the extracellular
space, regardless of whether there is capillary leakage. Option E
is not the best response.
Solution to Question 5
A slow, regular heart rate increases the portion of the cardiac
cycle spent quietly in diastole and is ideal for image quality.
Heart rates greater than 65 beats per minute increase motion ar-
tifacts and reduce the image quality of portions of the coronary
arteries, particularly the right coronary artery. Premedication
with -adrenergic receptor blocking agents ( -blockers) is recom-
mended to reduce the heart rate before CT angiography [15],
particularly in patients with heart rates greater than 65 beats
American Journal of Roentgenology 2006.187:S500-S504.
per minute. Contraindications for -blocker therapy include
asthma, atrioventricular conduction block, heart failure, diabe-
tes, and Raynaud syndrome. Option A is the best response.
Retrospective ECG gating is used for coronary CT angiogra-
phy studies performed on an MDCT scanner [15]. Because the
individual coronary vessels have different motion patterns, per-
forming individual reconstruction for each vessel with regard to
position in the cardiac cycle may optimize coronary segment vi-
sualization. The right coronary artery is best seen in early dias-
tole, the left circumflex artery is best seen in mid cycle, and the
left anterior descending artery is best seen in late diastole [16].
Option B is not the best response.
Calcium deposits in the coronary arteries attenuate the X-ray
beam, resulting in beam-hardening and partial volume artifacts.
Extensive calcification may interfere with accurate assessment
of stenosis [17, 18]. Option C is not the best response.
Scanning with 16-MDCT using standard protocols for coro-
nary CT angiography (120 kV, 400 mAs, 12 0.75 mm collima-
tion) results in an effective radiation dose of 8.1 mSv for men and
10.9 mSv for women [19]. This dose is higher than that of selec-
tive conventional coronary angiography (3–5 mSv). Option D is
not the best response.
Coronary arteries are small and move rapidly. Thus, imaging of
the coronary arteries requires high spatial and high temporal res-
olutions. Invasive, catheter-based coronary angiography has a
temporal resolutions (“shutter speed”) of approximately 6 milli-
seconds and a spatial resolution of approximately 0.25 mm [20].
The current generation of 64-MDCT scanners allow an isotropic
resolution of 0.4 × 0.4 × 0.4 mm at a gantry rotation speed of 330
milliseconds [21]. By applying a half-scan algorithm (only data
from a 180 gantry rotation are used for image reconstruction), ac-
quisition time can be reduced to 165 milliseconds. Thus, temporal
and spatial resolutions of CT angiography are still inferior to those
of conventional angiography. Option E is not the best response.
AJR:187, December 2006
Solution to Question 6
Evaluation of coronary bypass grafts is one of the first widely
accepted indications for contrast-enhanced CT angiography
[22]. CT with ECG gating may be particularly useful in symp-
tomatic patients during the immediate postoperative setting,
not only to evaluate graft patency but also to evaluate for other
conditions that can elicit similar symptoms to those of graft
stenosis or occlusion, such as pericardial effusion, pleural effu-
sion, sternal infection, and pulmonary embolism [23]. Delayed
complications, including late-onset graft occlusion or aneurysm
formation, are also well evaluated with CT. Further, if a revision
or repeat bypass surgery is needed, CT is useful in delineating the
existing grafts and complex postoperative anatomy for planning
before the procedure [23]. An emerging application is 3D-ren-
dered volumetric CT of the thorax and coronary arteries before
the initial bypass surgery, especially with the advent of mini-
mally invasive direct coronary artery bypass (MIDCAB) [22].
Option A is not the best response.
In the United States, up to two thirds of conventional cardiac
angiograms are obtained solely for diagnostic purposes. With the
latest generation of MDCT scanners, CT has become the noninva-
sive technique of choice for evaluating coronary artery stenosis.
Sensitivity ranges between 80% and 90% for hemodynamically
significant proximal coronary artery stenosis [22]. Furthermore,
a high negative predictive value (reported to be 97% with 16-
MDCT) suggests a role for noninvasive CT coronary angiography
to rule out significant coronary artery disease in patients with
equivocal clinical presentations and findings [22]. Option B is not
the best response.
Cross-sectional imaging has been recognized as the preferred
diagnostic strategy for the evaluation of coronary artery anom-
alies [22]. MRI is an excellent technique for evaluating suspected
coronary artery anomalies; however, MRI has shown limitations
in determining the distal course of the coronary vessels [23].
Therefore, CT is preferred for evaluating small collaterals, fistu-
las, aneurysms, and vessels originating outside the normal si-
nuses [22]. Option C is not the best response.
Coronary artery CT has no role in the management of acute
myocardial infarction when the diagnosis can be established by
clinical features, elevation of cardiac enzymes, and typical ECG
changes. Option D is the best response.
Pulmonary veins are an important source of ectopic atrial
electrical activity, causing atrial fibrillation. CT is ideally suited
for noninvasive visualization of the pulmonary venous return
and the left atrium before ablation therapy [22]. Option E is not
the best response.
Solution to Question 7
Patients presenting with acute chest pain are more likely to
have rapid, irregular heart rates and are unlikely to be able to
perform a lengthy breath-hold. The use of slower, older-genera-
tion CT scanners is therefore not practical. With the CT scanners
now available—namely, 64-MDCT—temporal resolution is
S503
 Attili et al.
vastly improved, thereby decreasing breath-hold times and
achieving diagnostic examinations even with higher, more irreg-
ular heart rates [22, 24]. Option A is not the best response.
CT angiography is best indicated for patients with an equivo-
cal presentation, nondiagnostic ECG, and initially negative se-
rum markers for acute myocardial infarctions. Those patients
with a high pretest probability of coronary artery disease (unsta-
ble angina with known coronary disease, sinus tachycardia, is-
chemic ECG changes, or positive cardiac enzyme markers) will
likely require a conventional workup, including catheter angiog-
raphy. Option B is not the best response.
With the use of 64-MDCT scanners, the concept of extending
cardiac angiography to include the pulmonary arteries and the
thoracic aorta has been actively discussed. The ability to evaluate
for hemodynamically significant coronary artery stenosis, pulmo-
nary embolism, and thoracic aortic dissection has obvious appeal
to the emergency department clinician. However, adequately
evaluating for these entities with one examination would require a
much larger field of view and volume of coverage as well as a longer
American Journal of Roentgenology 2006.187:S500-S504.
bolus of IV contrast material to enhance both the pulmonary and
thoracic vasculature [24]. Before implementation, this protocol
needs to be compared with the standard individual examinations,
and the clinical indication for this type of examination must be
carefully defined [22, 24]. Option C is the best response.
CT coronary angiography has a high negative predictive
value; therefore, significant coronary artery disease in patients
with acute chest pain should be safely ruled out by a negative ex-
amination [22]. Option D is not the best response.
Acute chest pain is a common presenting symptom in emer-
gency department patients. Most patients will not actually have
coronary syndromes. Option E is not the best response.
References
1. Basso C, Maron BJ, Corrado D, Thiene G. Clinical profile of congenital coronary ar-
tery anomalies with origin from the wrong aortic sinus leading to sudden death in
young competitive athletes. J Am Coll Cardiol 2000; 35:1493–1501
2. Schmitt R, Froehner S, Brunn J, et al. Congenital anomalies of the coronary
arteries: imaging with contrast-enhanced, multidetector computed tomogra-
phy. Eur Radiol 2005; 15:1110–1121
3. Post JC, van Rossum AC, Bronzwaer JG, et al. Magnetic resonance angiogra-
phy of anomalous coronary arteries: a new gold standard for delineating the
proximal course? Circulation 1995; 92:3163–3171
ARRS members earn free CME and SAM credit at www.arrs.org.
Select Journals/Integrative Imaging from the navigation menu on the left of the home page.
S504
4. Bunce NH, Lorenz CH, Keegan J, et al. Coronary artery anomalies: assessment
with free-breathing three-dimensional coronary MR angiography. Radiology
2003; 227:201–208
5. Alegria JR, Herrmann J, Holmes DR Jr, Lerman A, Rihal CS. Myocardial
bridging. Eur Heart J 2005; 26:1159–1168
6. Angelini P, Velasco JA, Flamm S. Coronary anomalies: incidence, pathophys-
iology, and clinical relevance. Circulation 2002; 105:2449–2454
7. Robinson FC. Aneurysms of the coronary arteries. Am Heart J 1985; 109:129–135
8. Swaye PS, Fisher LD, Litwin P, et al. Aneurysmal coronary artery disease. Cir-
culation 1983; 67:134–138
9. Wooditch AC, Aronoff SC. Effect of initial corticosteroid therapy on coronary
artery aneurysm formation in Kawasaki disease: a meta-analysis of 862 chil-
dren. Pediatrics 2005; 116:989–995
10. Murthy PA, Mohammed TL, Read K, Gilkeson RC, White CS. MDCT of cor-
onary artery aneurysms. AJR 2005; 184[suppl]:S19–S20
11. Kim RJ, Wu E, Rafael A, et al. The use of contrast-enhanced magnetic reso-
nance imaging to identify reversible myocardial dysfunction. N Engl J Med
2000; 343:1445–1453
12. Selvanayagam JB, Kardos A, Francis JM, et al. Value of delayed-enhancement
cardiovascular magnetic resonance imaging in predicting myocardial viability
after surgical revascularization. Circulation 2004; 110:1535–1541
13. Edelman RR. Contrast-enhanced MR imaging of the heart: overview of the lit-
erature. Radiology 2004; 232:653–668
14. Simonetti OP, Kim RJ, Fieno DS, et al. An improved MR imaging technique
for the visualization of myocardial infarction. Radiology 2001; 218:215–223
15. Lawler LP, Pannu HK, Fishman EK. MDCT evaluation of the coronary arter-
ies, 2004: how we do it—data acquisition, postprocessing, display, and inter-
pretation. AJR 2005; 184:1402–1412
16. Kopp AF, Schroeder S, Kuettner A, et al. Coronary arteries: retrospectively
ECG-gated multi-detector row CT angiography with selective optimization of
the image reconstruction window. Radiology 2001; 221:683–688
17. Ropers D, Baum U, Pohle K, et al. Detection of coronary artery stenoses with
thin-slice multi-detector row spiral computed tomography and multiplanar re-
construction. Circulation 2003; 107:664–666
18. Nieman K, Rensing BJ, van Geuns RJ, et al. Usefulness of multislice computed
tomography for detecting obstructive coronary artery disease. Am J Cardiol
2002; 89:913–918
19. Trabold T, Buchgeister M, Kuttner A, et al. Estimation of radiation exposure
in 16-detector row computed tomography of the heart with retrospective ECG-
gating. Rofo 2003; 175:1051–1055
20. Achenbach S, Daniel WG. Computed tomography of the coronary arteries:
more than meets the (angiographic) eye. J Am Coll Cardiol 2005; 46:155–157
21. Leber AW, Knez A, von Ziegler F, et al. Quantification of obstructive and non-
obstructive coronary lesions by 64-slice computed tomography: a comparative
study with quantitative coronary angiography and intravascular ultrasound. J
Am Coll Cardiol 2005; 46:147–154
22. Schoepf UJ. CT angiography of the coronary arteries. Radiology 2004; 232:18–37
23. Frazier AA, Qureshi F, Read KM, Gilkeson RG, Poston RS, White CS. Coro-
nary artery bypass grafts: assessment with multidetector CT in the early and
late postoperative settings. RadioGraphics 2005; 25:881–896
24. Hoffman U, Pena AF, Cury RC, et al. Cardiac CT in emergency department pa-
tients with acute chest pain. RadioGraphics 2006; 26:963–980
AJR:187, December 2006