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Table of Contents
Year : 2011  |  Volume : 14  |  Issue : 2  |  Page : 134-145
Role of multimodality cardiac imaging in preoperative cardiovascular evaluation before noncardiac surgery

1 Department of Medical Imaging Service, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
2 King Faisal Heart Institute, King Faisal Specilaist Hospital and Research Center, Riyadh, Saudi Arabia; The heart Center, St Lukes Episcopal Hospital, Texas Heart Institute, Houston,Texas, USA

Click here for correspondence address and email

Date of Submission26-Oct-2010
Date of Acceptance04-Mar-2010
Date of Web Publication25-May-2011


The preoperative cardiac assessment of patients undergoing noncardiac surgery is common in the daily practice of medical consultants, anesthesiologists, and surgeons. The number of patients undergoing noncardiac surgery worldwide is increasing. Currently, there are several noninvasive diagnostic tests available for preoperative evaluation. Both nuclear cardiology with myocardial perfusion single photon emission computed tomography (SPECT) and stress echocardiography are well-established techniques for preoperative cardiac evaluation. Recently, some studies demonstrated that both coronary angiography by gated multidetector computed tomography and stress cardiac magnetic resonance might potentially play a role in preoperative evaluation as well, but more studies are needed to assess the role of these new modalities in preoperative risk stratification. A common question that arises in preoperative evaluation is if further preoperative testing is needed, which preoperative test should be used. The preferred stress test is the exercise electrocardiogram (ECG). Stress imaging with exercise or pharmacologic stress agents is to be considered in patients with abnormal rest ECG or patients who are unable to exercise. After reviewing this article, the reader should develop an understanding of the following: (1) the magnitude of the cardiac preoperative morbidity and mortality, (2) how to select a patient for further preoperative testing, (3) currently available noninvasive cardiac testing for the detection of coronary artery disease and assessment of left ventricular function, and (4) an approach to select the most appropriate noninvasive cardiac test, if needed.

Keywords: Cardiac CT, cardiac imaging, cardiac MR, cardiac SPECT, preoperative evaluation, stress echocardiography

How to cite this article:
Fathala A, Hassan W. Role of multimodality cardiac imaging in preoperative cardiovascular evaluation before noncardiac surgery. Ann Card Anaesth 2011;14:134-45

How to cite this URL:
Fathala A, Hassan W. Role of multimodality cardiac imaging in preoperative cardiovascular evaluation before noncardiac surgery. Ann Card Anaesth [serial online] 2011 [cited 2022 Oct 3];14:134-45. Available from:

   Introduction Top

The number of patients undergoing noncardiac surgery worldwide is growing, and annually 5,000,000 to 900,000 of these patients experience major cardiac events such as cardiac death and nonfatal myocardial infarction (MI), or nonfatal cardiac arrest. The majority of patients being considered for elective noncardiac surgery should be able to undergo surgery without difficulty and an overall cardiac event rate of less the 2% should be considered the acceptable goal. However, in a selected subpopulation based on clinical risk factors, patients' functional capacity, and type of surgery, additional noninvasive testing should be obtained. Therefore, preparative cardiac risk stratification with stress testing (with or without imaging) must be considered in a variety of clinical conditions for complete and optimum consultation.

Noninvasive cardiac imaging is now central to the diagnosis and management of patients with known or suspect coronary artery disease (CAD). Stress myocardial perfusion scintigraphy (MPS) with single photon emission computed tomography (SPECT) and stress echocardiography play an important role in preoperative cardiac evaluation. Stress testing with or without imaging is recommended in certain patients by most recent guidelines. More recently, cardiac CT (CCT) and cardiac magnetic resonance (CMR) have played important and emerging roles in patients with CAD. However, currently, there are no enough data to support the clinical utility of this relatively new imaging technique in preoperative cardiac evaluation. CCT is considered an uncertain indication, as per appropriateness criteria, for preoperative evaluation. In addition, several noninvasive cardiac modalities are available for the assessment of left ventricle ejection fraction (LVEF) before elective surgery including the above-mentioned noninvasive modalities and equilibrium radionuclide angiography (ERNA). This review will discuss the current applications of noninvasive imaging approaches for preoperative cardiac evaluation and will consider the strengths and weaknesses of each technique.

   Magnitude of the Problem Top

Noncardiac surgery has made substantial advances in treating disease (for example, cancer surgery) and improving quality of life (e.g., arthroplasty). As a result, the number of patients undergoing noncardiac surgery is generally increasing worldwide. [1] However, such surgery is associated with significant cardiac morbidity, mortality, and subsequent cost. Patients undergoing noncardiac surgery are at risk of major cardiac events (cardiac death, nonfatal MI, and nonfatal cardiac arrest); patients experiencing an MI after noncardiac surgery have a hospital mortality rate of 15-25%. [2] Nonfatal perioperative MI is an independent risk factor for cardiovascular death and nonfatal MI during the 6 months following surgery. Furthermore, patients who have a cardiac arrest after noncardiac surgery have a hospital mortality rate of 65%, and a nonfatal perioperative cardiac arrest is a risk factor for cardiac death. [3]

   Major Parameters that Determine the Cardiac Risk before Noncardiac Surgery Top

Patients' clinical risk factors

The clinical risk factors are not the traditional risk factors for atherosclerosis that were originally defined in the Framingham Heart study (i.e., hypertension, hyperlipidemia, tobacco abuse, diabetes mellitus, family history of premature atherosclerosis, etc.) and rather the clinical risk factors based on American College of Cardiology Foundation/American Heart Association ACCF/AHA guidelines that have been associated in a variety of studies with an increased risk for cardiac events at the time of noncardiac surgery. The following six independent predictors were identified in the Revised Cardiac Risk Index: stable ischemic heart disease, compensated heart failure, cerebrovascular disease, diabetes mellitus requiring preoperative insulin therapy, a preoperative creatinine level greater than 2 mg/dl (176.8 μmol/l), and high-risk noncardiac surgery. [4],[5]

Patients' functional capacity

Patients with a good functional capacity can proceed with their planned surgery without further preoperative assessment or specific therapy. A good functional capacity is generally defined on the basis of metabolic equivalent (MET) levels. For reference purpose, activates of daily living, such as eating, dressing, and showering, typically require 1-2 METs, whereas, strenuous sports require more than 10 METs. A patient who never leaves a single-level house because of cardiac symptoms has a poor functional capacity. A more detailed clinical history will be required to determine the functional capacity; a simple question can provide a clue in making a reasonable estimate of the patient's functional capacity. [4]

Surgery-specific cardiac risk

Procedure-specific cardiac risk can be important, especially in patients with more than two clinical risk factors. The ACC/AHA guidelines identify these categories of surgery-specific risk. [4]

Vascular surgery (the highest risk category) has been associated with cardiac mortality rates of greater than 5% in many reports; examples include major vascular surgery and peripheral vascular surgery.

For intermediate-risk surgery, reported cardiac mortality rates range from 1% to 5%; examples include head and neck surgery, orthopedic surgery, and prostate surgery.

For low-risk surgery, the reported cardiac mortality rate is generally below 1%. Examples include cataract surgery, breast surgery, and endoscopic surgery.

Active cardiac conditions

Active cardiac conditions include unstable coronary syndrome, decompensated heart failure, substantial arrhythmias, and severe mitral or aortic stenosis. The presence of one or more active cardiac conditions increases the risk of cardiac mortality and mortality. Except when emergency noncardiac surgery is warranted, these active cardiac conditions preclude the proceeding with noncardiac surgery without further evaluation and management of the cardiac problem. Neither operative coronary intervention nor percutaneous coronary intervention (PCI) is usually necessary to lower the risk of noncardiac surgery unless such intervention is indicated for the benefits of the patients irrespective of the preoperative context.

Emergency versus elective surgery

Patients with acute life-threatening conditions require emergency surgical intervention proceeding to surgery as soon as possible without extensive cardiac assessment. Examples include ruptured aortic aneurysm, acute subdural hematoma with papilledema, and life-threatening acute trauma. Recommendations for preoperative surveillance and management are appropriate in patients with preexisting cardiac conditions. Further cardiac evaluation and risk factor management must be deferred to postoperative period.

The key recommendations for cardiac evaluation

A stepwise approach takes into account the patient's clinical risk factors, functional capacity, type of surgery and its risk level, the presence or absence of active cardiac condition, and the urgency of surgery. The followings are the key recommendations. [4]

  • Patients requiring urgent noncardiac surgery should proceed to the operating room with preoperative surveillance.
  • Patients with active cardiac condition should be evaluated and treated before nonemergency surgery.
  • Patients scheduled for low-risk surgery can proceed to the surgery without further testing.
  • Patients scheduled for intermediate-risk surgery or vascular surgery can proceed without further testing if they have a good functional capacity.
  • In patients with a poor functional capacity or unknown functional capacity who have three or more risk factors, testing should be considered if the result would change the management.
  • Patients undergoing intermediate risk surgery or vascular surgery who have a poor functional capacity or unknown functional capacity but no clinical risk factors may proceed to surgery without further testing.
  • Patients with fewer than three risk factors undergoing vascular surgery and those with one or more clinical risk factors undergoing intermediate risk surgery may proceed to surgery with control of the heart rate or they may undergo noninvasive testing, but only if the results would change the management.

Current noninvasive diagnostic testing for coronary artery disease

Noninvasive cardiac imaging is now central to the diagnosis and management of patients with known or suspected chronic CAD. Many noninvasive diagnostic modalities are available to the consulting physicians in cardiac perioperative evaluation; they include stress MPS, stress echocardiography CCT, and stress CMR.

Stress myocardial perfusion scintigraphy

Stress MPS has become one of the most widespread tools for the assessment of all aspects of CAD. It is useful in the diagnosis, risk stratification, assessment of response after intervention or therapy, and myocardial viability assessment. Gated SPECT for detecting regional and global left ventricular (LV) function has provided incremental diagnostic and prognostic information of patients with suspected or known CAD. The LVEF and regional myocardial wall thickening can be simultaneously evaluated with gated SPECT. Furthermore, the extensive literature indicates that gated SPECT allows a more accurate and reliable prognostic stratification in patients with known or suspected CAD.

Role of MPS in the detection of CAD

The sensitivity and specificity for the detection CAD by gated SPECT is in average 91% and 72%, respectively.[6] These values are consistent and independent of the subpopulation (i.e., women, obese, and diabetic patients). A recent meta-analysis of large studies, including 201 TI- and 99m Tc-labeled tracer sestamibi and tetrofosmin and either exercise or pharmacological stress test, reported an average sensitivity of 87% and specificity of 73% for the detection of angiographically significant CAD. [7] In the last 10 years, a decline in the apparent specificity of MPS has been observed because of post-stress referral bias. The normalcy rate (the percentage of patients with a below 5% likelihood of disease with normal MPS) correct for referral bias is estimated at 91%.

As per current guidelines, MPS is recommended as class 1 indication for the detection of obstructive CAD in patients with intermediate pretest probability of the disease. [8],[9],[10] In addition, in patients with known CAD and prior revascularization, all guidelines gave MPS a class 1 indication as the initial test in patients presenting with recurrent chest pain; the usefulness of MPS in this population relies on its ability to define the site and severity of ischemia, an important consideration for further management that cannot be assessed accurately by exercise ECG. The accuracy of MPS has been compared with that of stress echocardiography, generally showing MPS to have a higher sensitivity and equivalent specificity.

The prognostic value of MPS

The prognostic value of MPS has been established in large cohorts of patients with a variety of risk factors. [11],[12],[13] Generally, normal MPS in patients with intermediate to high likelihood predicts a very low event rate (less than 1% a year), leading to a negative predictive value of more than 99%. However, abnormal MPS in patients with intermediate to high likelihood of CAD increases the annualized event rate with a factor of more than 7%, and the risk of event is related to the severity of perfusion abnormalities (from 3% annual death or myocardial infarction with mild or moderate perfusion defect up to 7% in patients with severe perfusion abnormalities). Very importantly, the markers of LV dysfunction are more efficient in the prediction of death, where markers of ischemia have better proven of ischemia, such as recurrent chest pain or nonfatal MI.

MPS for risk assessment before noncardiac surgery

A large meta-analysis study (10 studies, 1994 patients) conducted by Shaw et al. showed the significant prognostic utility of dipyridamole MPS for risk stratification before elective vascular surgery. [14] In addition, it was found that the positive predictive value of perfusion imaging was correlated to the pretest cardiac risk of patients. A reversible myocardial perfusion defect predicts the long-term cardiac events. Semiquantitative analysis of myocardial perfusion imaging improved the clinical risk stratification by defining a relationship of the increasing risk of cardiac event with defect size increase.

Other three articles support the use of selective testing for vascular surgery patients according to the clinical algorithm that is similar to ACCF /AHA guidelines. [15],[16],[17] These data also suggest that the increased risk is associated with higher segmental perfusion abnormalities.

It is equally important to note that normal MPS in a clinically high-risk patient group is associated to a low event rate, which is equivalent to that observed in patients without any risk predictors [Figure 1]. Therefore, the presence of normal MPS in high-risk patients appears to identify an otherwise undetected low-risk subgroup that is equivalent to a group with no clinical risk factors.
Figure 1: Normal myocardial perfusion SPECT in a 67-year-old male being considered for vascular surgery. The short axis (SAX), vertical long axis (VLA), and horizontal long axis (HLA) are showed. The top rows are stress images and lower rows are rest images. Both stress and rest images show a normal distribution; a small area of a mild decreased uptake noted in the basal septum (arrows) is indicating normal membranous septum. The negative predictive value of a normal MPS scan is approximately 99%.

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Stress echocardiography

Myocardial ischemia is accompanied by characteristic mechanical, electrical, and perfusion abnormalities. Stress echocardiography detects ischemia by inducing wall motion abnormalities. The coupling between the level of ischemia and regional contraction suggests that stress-inducible wall motion abnormalities are a sensitive and meaningful marker for an acute ischemic event.[18] In general, the use of stress testing to induce LV contractile abnormalities is based on myocardial metabolic demand side of the equation is highly dependable on many factors including LV pressure volume, wall stress, heart rate, and contractility. All of these parameters are related to myocardial oxygen consumption through a combined effect on LV wall forces linked together by Marque de La Place's equation (product of the intracavity pressure and radius of curvature of the myocardial segment divided by wall thickness).

Methods of stress echocardiography

Exercise stress echocardiography

The exercise protocol includes a treadmill exercise test with immediate postexercise echocardiographic images or upright or supine bicycle echocardiographic images obtained at peak exercise. [19],[20] Immediate postexercise images can be compared with baseline pre-exercise images to detect exercise-induced wall motion abnormalities. The main advantage of treadmill exercise testing is that it provides excellent natural physiologic cardiovascular stress, making physicians familiar with ECG changes and symptoms and allowing these to be analyzed with stress echocardiography images to detect ischemia-induced wall motion abnormalities The main disadvantage of using treadmill exercise echocardiography is that imaging cannot be obtained through the stress test and can only be performed immediately after the cessation of exercise. The second disadvantage is that a high respiratory rate and heart rate produce optimum echocardiographic imaging when recorded on videotape. For this reason, digital technology must be used on in type of stress echocardiography.

Pharmacological stress echocardiography

When patients cannot exercise, ischemia is induced pharmacologically with dobutamine, dipyridamole, or adenosine. [21],[22],[23] Dobutamine is the most commonly used agent in stress echocardiography because insufficient triggering wall motion abnormalities in a satisfactory way to be clinically useful. [24] Stress echocardiography is very safe with no procedure mortality. Paradoxical hypotension occurs in approximately 20% of patients. [25] Sustained ventricular tachycardia during dobutamine stress echocardiography is a rare complication. The clinical significance of dobutamine stress echocardiography-induced ventricular tachycardia is uncertain and this condition probably does not represent an adverse prognostic sign. [26]

Diagnostic accuracy of stress echocardiography

Quinones et al. reported that the overall sensitivity and specificity of exercise echocardiography were 85% and 88%, respectively. The sensitivity of exercise echocardiography for single, double, and triple vessels was 58%, 86%, and 94%. [27] In addition, another study showed that dobutamine stress echocardiography has a sensitivity of range 61-95%. The increment in the cardiac workload is reduced by medical treatment or the dose-limiting side effect. [28] The sensitivity and specificity of dipyridamole and adenosine stress echocardiography for the detection of CAD are 61% and 81%, respectively. Single vessel disease is more difficult to be detected by this technique.

Prognosis of stress echocardiography

The likelihood of a cardiac event (cardiac death, nonfatal infarct, or coronary revascularization) occurring after normal results obtained for stress echocardiography is extremely low. At Mayo Clinic, among 1325 patients with normal findings on exercise echocardiography, the event rate over 3 years of follow-up was less than 3%. [29] A meta-analysis study reported that normal stress echocardiography yields an annual risk of 0.4-0.9% for a total of 9000 patients, the same for normal myocardial persons. Thus, in patients with suspect CAD, a normal stress echocardiography implies excellent prognosis and coronary angiography can be safely avoided. Physical or physiological stress echocardiography has comparable prognosis stratification. [30]

Stress echocardiography in preoperative evaluation

The most common indication for dobutamine stress echocardiography is preoperative cardiac evaluation. The test combines information on the LV function at rest, heart valve abnormalities, and the presence and extent of stress-induced ischemia. In 530 patients, stress echocardiography was performed for the assessment of cardiac risk before nonvascular surgery, multivariable prediction of postoperative events in patients with ischemia were found to be history heart failure and ischemia threshold less than 60% of predicted maximum heart rate. [30] DSE identified 60% of patients as low risk (no ischemia), 32% as intermediate risk (ischemia threshold more than 60%), and 8% as high risk (ischemia threshold less than 60%); postoperative event rates were 0%, 9%, and 43%, respectively. DSE has some limitations, e.g., it should not be used in patients with severe arrhythmias, significant hypertension, large thrombus-laden aortic aneurysm, or hypotension.

Cardiac computed tomography

Recent technological advances (both hardware and software) in X-ray CT imaging over the past few years have made it the leading technique for providing noninvasive imaging of the coronary artery. Developed in 1991, the Elscint CT Twin model was the first multislice CT (MSCT) scanner and had two parallel barks of X-ray detectors to acquire two slices for each gantry rotation. Quickly, the technology developed with scanners with few slices, then 16 slices, then 64 slices, and the current scanners have up to 256 and 320 slices. In addition, currently dual source MSCT is available; this has two pairs of X-ray sources and multiple detectors mounted at 90 to each other. Dual source MSCT provides faster scanning and achieves a temporal resolution of 83 ms. Electron-beam CT (EBCT) scanner was launched in 1990. It provides very high temporal resolution owing to electric sweeping of the electron beam which can be captured much faster than the mechanical rotation of MSCT. EBCT has been extensively used in calcium scoring of the coronary artery but has a poor spatial resolution. MSCT can perform accurate calcium scoring and is more widely available than EBCT.

Cardiac CT and detection of coronary artery stenosis

A recent meta-analysis showed a significant improvement in the accuracy for the detection of coronary artery stenosis by 64-slice CT when compared with previous scan generations.[31] The weighted mean sensitivity for the detection of coronary artery stenosis increased from 84% for 4-slice CT and 83% for 16-slice CT to 93% for 64-slice CT, whereas the respective specificities were 93%, 96%, and 96%, respectively. Most of the accuracy data that are currently available concerning the detection of coronary artery stenosis by CT angiography have been obtained in patients groups with suspected CAD and stable symptoms. The consistently high negative predictive value in all studies suggests that CT angiography will be clinically useful in this patient group. In patients with a very high pretest likelihood of the disease, the use of CT angiography will most likely not result in a scan (negative) that would help avoid invasive angiography. Therefore, the use of CT angiography should be restricted to the patients with an intermediate pretest likelihood of CAD.

Several studies have evaluated the accuracy of CT angiography in specific patient populations. In patients with dilated cardiomyopathy, the sensitivity of CT angiography was 99%, specificity 96%, and positive and negative predictive values 93% and 97%, respectively; in patients with left bundle branch block, LBBB, the sensitivity was 97%, specificity 95%, and positive and negative predictive values 93% and 97%, respectively.[32],[33] Hoffman et al. conducted a prospective study in group of patients with acute chest pain. This was performed for risk stratification in patients with chest pain, absence of ECG changes, and negative cardiac enzymes. The negative predictive value was 100%, with a rather low positive predictive value of 47%; the low positive predictive value was most likely due to the small percentage of patients included in the study (103 of 305 initially screened patients). [34]

Cardiac CT for preoperative risk stratification

One potential role of CCT may be preoperative cardiac evaluation in patients who are referred for noncoronary cardiac surgery [Figure 2]. Several studies have evaluated the accuracy of CT angiography in preoperative evaluation. Meijboom et al. studied the diagnostic performance of 64-slice MDCT in patients referred for valve surgery, and reported a sensitivity of 100% with a specificity of 92% and positive and negative values of 82% and 100% respectively, to identify patients with at least one significant stenosis. [35] Russo et al. conducted a study on 132 patients who underwent MDCTCA for the assessment of the cardiac risk profile before surgery. Coronary arteries were screened for >50% stenosis. Patients without significant stenosis (Group 1) underwent surgery without any adjunctive screening tests while all patients with coronary lesions >50% at MDCTCA (Group 2) underwent CA. No severe cardiovascular perioperative events such as myocardial ischemia, myocardial infarction, or cardiac failure occurred in any patient in Group 1, but 30 out of 36 patients with significant (>50%) coronary stenosis at MDCTCA and CA underwent adjunctive bypass surgery or coronary angioplasty. In eight patients, MDCTCA overestimated the severity of the coronary lesions. Author's main conclusion was that MDCTCA seems to be effective as a preoperative screening test prior to noncoronary cardiac surgery and may become the method of choice for the assessment of a cardiovascular risk profile prior to major surgery. [36] Finally, Gillard et al. studied the role of MDCT coronary angiography in patients with severe valve disease. The sensitivity was 100%, specificity 80%, and positive predictive value and negative predictive values were 55% and 100%, respectively. [37]
Figure 2: (a) Nondiagnostic myocardial perfusion scan in a 63-year-old female with colon cancer; myocardial perfusion SPECT was performed for preoperative risk stratification. Selected short axis images demonstrating an extensive extracardiac activity adjacent to the inferior wall render the study nondiagnostic due to normalization of the extracardiac activity (arrows). (b) Computed tomography coronary angiography was performed on the next day and showed normal coronary arteries. The patient underwent successful surgery without perioperative complications. LM, left main coronary artery; LAD, left anterior descending artery; RCA, right coronary artery.

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Currently, no data are available in the setting of preoperative evaluation risk scarification. As per ACC appropriateness criteria, CCT for preoperative evaluation is classified as uncertain with a score of 4 (The score 4-6 uncertain for specific indication indicates that the test may be generally acceptable and may be a reasonable approach for the indication, and uncertainty also implies that more research and/or patient information is needed to classify the indication definitively.) [38] The use of CT scans has some limitations such as the need of IV iodine contrast media that may cause allergic reaction or extravasation and it is contraindicated in patients with a poor renal function. Ionizing radiation is one of the most important limitations of CT scanning. The effective radiation dose of contrast-enhanced CT is 5-20 mSv. Radiation reduction can be achieved by keeping the scan volume as small as possible, low tube current, and tube modulation. Recently, prospective ECG gating (stop and shot technique) can minimize radiation exposure provided that LV function is not required. The radiation dose of cardiac CT is in the same order of magnitude as nuclear myocardial perfusion (with a typical dose of 8-25 mSv). However, all possible measures should be taken to keep the dose as low as possible, and considerations for clinical indications for cardiac CT must always take radiation exposure into account. [39],[40]

Cardiac magnetic resonance

CMR has recently become one of the major noninvasive cardiac techniques for several cardiovascular disorders. Numerous clinical and experimental studies have demonstrated the equality or even superiority of other established cardiovascular imaging techniques, particularly avoiding ionizing radiation such as in MPS or CCT and poor acoustic window such as in echocardiography. Also, one of the major advantages of CMR is high spatial and temporal resolution. Currently, there are several clinical applications of CMR, mainly in myocardial viability, myocardial perfusion, valvular heart disease, differential diagnosis of cardiomyopathy, and congenital heart disease.

At present, there are a number of CMR approaches for the detection of CAD: (1) coronary magnetic angiography (CMRA), (2) stress CMR with dobutamine to assess the contractile reserve and inducible wall motion abnormalities, and (3) stress CMR with adenosine to assess myocardial perfusion reserve.

Coronary MRA may be used to directly visualize coronary artery anatomy and morphology. [41],[42] However, coronary MRA is technically demanding for several reasons. The coronary arteries are small and tortuous and in near-constant motion form a breathing and cardiac cycle. Coronary MRA is class 2a recommendation for the detection of coronary artery anomalies but it is not recommended for the detection of CAD. [43]

Dobutamine stress CMR detects ischemia-induced wall motion abnormalities, and it is a well-established technique for the diagnosis of CAD. It yields a higher diagnostic accuracy than dobutamine stress echocardiography and can be used effectively in patients not suited for echocardiography because of poor acoustic window. [44],[45] Nonetheless, patient safety and monitoring are main issues that require thorough paining and experienced personnel.

Adenosine stress CMR

Currently, adenosine CMR is considered a competitive first-line test for the evaluation of CAD. In 2006, a consensus panel from ACCF considered the following indications as appropriate indications for stress CMR: (1) evaluating chest pain in patients with intermediate probability of CAD and (2) assessing the severity of intermediate coronary artery lesions.

During pharmacological vasodilatation (with adenosine), the myocardial blood flow increases four to five times in a normal coronary artery, but not significantly in a severely diseased artery. This physiologic difference results in a lower peak myocardial signal intensity in the region supplied by the diseased vessel. The signal intensity difference can be evaluated visually or quantitatively. [46]

Diagnostic performance of stress CMR

A number of studies demonstrated a good correlation between MPS and coronary angiography. [47] In a total of 21 studies consisting of 1233 patients with known or suspected CAD, on average, the sensitivity and specificity of CMR was 84% and 80%, respectively. In a recent clinical consensus, CMR perfusion considered class 2 indications. [48]

Stress CMR for CAD risk stratification

Normal stress CMR predicts good prognosis for cardiac death and nonfatal MI, with an event rate of 0.07% per year over 2 years after a CMR study [Figure 3]. Jahnke et al. performed combined stress perfusion CMR and dobutamine stress CMR in a series of 513 patients with known or suspected CAD and demonstrated a 97.7% rate of survival free from cardiovascular death or nonfatal MI at 3 years in patients with normal perfusion CMR (50). Furthermore, perfusion CMR is also applicable in acute chest pain in the emergency room. A negative perfusion CMR study showed a 100% sensitivity and a positive perfusion CMR study a 91% specificity to predict future cardiac events, i.e., MI, death, CAD on invasive CA, or abnormal MPS. [49],[50]
Figure 3: Normal stress cardiac magnetic resonance (CMR) perfusion imaging using adenosine in a 54-year-old female with chest pain. The top row images are stress short-axis images from the apex to the base and lower row images are rest short-axis images in the same orientation. Normal stress CMR predicts good prognosis for cardiac death and nonfatal MI, with an event rate of 0.07% per year over 2 years after the CMR studyles out significant hypovolemia. An area of 16.5 cm2 is shown in this image

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Although further studies are required, early studies suggest that a normal stress CMR is associated with a low likelihood of a future cardiovascular event, at least in the short term and intermediate term. Although CMRI is a safe diagnostic tool, it cannot be performed in patients with active devices such as pacemakers, implantable cardioverter-defibrillators (ICDs), insulin pumps, and others. Claustrophobia is a relative contraindication of CMRI imaging. Nephrogneic systemic fibrosis (NSF), a rare syndrome characterized by fibrosis of skin and connective tissue, has been reported in patients with renal dysfunction typically with a glomerular filtration rate of less than 30 ml/min/1.73m 2 .

Assessment of the left ventricular function

LVEF in preoperative period is mainly predictive of postoperative heart failure, and not consistently a predictor of perioperative ischemic event such as MI. In a meta-analysis study comprising 8 studies, the preoperative resting LVEF was calculated by equilibrium radionuclide angiography (ERNA). The LVEF of 35% had a sensitivity of 50% and specificity of 91% in the prediction of postoperative nonfatal MI or cardiac death. [51] ACCF/AHA recommended the preoperative noninvasive evaluation of the LV function in the following conditions: patients with dyspnea of an unknown etiology, patients with current or prior HF, clinically stable patients with previously documented cardiomyopathy not established. The routine preoperative evaluation of the LV function is not recommended.

Assessment of the LVEF: Current noninvasive techniques 2D Echocardiography

Two-dimensional (2D) echocardiography is the most widely used technique to assess the LFEF. Its major advantages are ease of examination, low cost, bedside availability, and absence of ionizing radiation. [52],[53],[54] However, there are several limitations of echocardiography; for example, inadequate delineation of endocardium and myocardial trabucluation and papillary muscle obscure the true LV borders. More recently, contrast echocardiography more accurately estimates the LV function with a high interobserver agreement. The inherent drawback of 2D echocardiography in the calculation of the LVEF and LV volumes is the geometric assumption that leads to the inaccurate estimation of the LV function particularly in patients with regional wall motion abnormalities and an asymmetrical irregular ventricle. [55] The development of real-time 3D echocardiography has eliminated the previously mentioned shortcoming of 2D images. It has been validated for its accuracy and high reproducibility for the measurement of LV volume and global LV function. However, poor acoustic window and imaging artifact still remain a significant hurdle and these significantly reduce the accuracy of volumetric measurement by 3D echocardiography.

Equilibrium radionuclide angiocardiography

The nuclear medicine technique most commonly used to assess the ventricular function is termed as equilibrium radionuclide angiocardiography (ERNA). In ERNA, the LVEF is determined without assuming the shape of the heart; it is based on the principle that counts in the left ventricle are proportional to volume. Using the best septal view, outlines of the LV in end-diastole and end-systole are drawn by an edge detection program. Note that no assumption is made for the shape of the heart. It is widely used mainly in oncology for the monitoring and early detection of the cytotoxic effect in drug-induced cardiomyopathy. In a multicentral study, using echocardiography, CMR, and ERNA for the assessment of the LVEF, ERNA was found to underestimate the LVEF when compared to CMR particularly in patients with a LV dysfunction and low LVEF of 35%. [56],[57]


CMR is considered to be the current noninvasive reference standard for the assessment of the LVEF and LV volumes. The assessment of the LV function by CMR is operator independent and does not depend on geometric assumption. [58],[59] It has high reproducibility and low interobserver variability. Some of the limitations of CMR are limited availability, high cost, and contraindication in patients with pacemakers.


MPS can assess myocardial perfusion and LV volumes and function. The assessment of the LVEF using gated MPS has been well validated by comparison with other imaging modalities such as 2D echocardiography, ERNA, and CMR. A number of studies have suggested that the measurement of LVEF by using quantitative gated SPECT is reproducible and accurate even in the presence of large severe perfusion defects. [60] However, radiation exposure is a major concern, and it is not recommended to order gated MPS for function only unless combining perfusion with function in patients with suspected CAD.

Cardiac CT

The assessment of the LVEF and LV volumes can also be performed with gated CCT. Several studies showed an excellent correlation with other noninvasive modalities such as 2D echocardiography and CMR. [61],[62] But it is unreasonable to order CCT for the assessment of the LVEF only due to high radiation exposure and availability of echocardiography and CMR.

How to select the preoperative cardiac stress test (with or without imaging)?

  • Treadmill is the test of choice if a patient is able to exercise. It not only detects myocardial ischemia but also estimates the functional capacity.
  • Pharmacological stress test with adenosine, dipyridamole, or dobutamine MPS and echocardiography are recommended for patients who are unable to exercise, have abnormal baseline ECG or left ventricular hypertrophy or are on digoxine.
  • Dobutamine is contraindicated in patients with severe arrhythmias, severe hypertension, or hypotension.
  • Adenosine and dipyridamole are contraindicated in patients with severe bronchospasm, carotid artery occlusion, or when theophyline preparation or adenosine cannot be withdrawn.
  • Vasodilator stress test is recommended for patients with LBBB to decrease the probability of false septal ischemia.
  • In patients with poor quality rest echocardiographic images due to poor acoustic window, MPS is more appropriate, or stress MR can be used, if available.
  • Dobutamine stress echocardiography is recommended if a patient is known to have a cardiac murmur.
  • It is difficult to anticipate MPS with significant artifacts or pitfalls; however, high-quality MPS images with attenuation correction, more delayed images, or prone images must be considered if there is a significant attenuation artifact. As per our experience, we found that CCT is very helpful if MPS was not diagnostic or equivocal.
  • There is growing and emerging evidence supporting a potential role of both stress CMR and coronary CTA in preoperative cardiac evaluation.
  • Coronary CTA, based on author experience, is an excellent tool in patients with intermediate probability of CAD, and especially in patients with LBBB, dilated cardiomyopathy, and nondiagnostic MPS.
  • The expertise of the interpreting physician and availability of stress test and cardiac imaging vary from one facility to another. The consulting physician must be familiar with his or her local resources.
  • For the assessment of the LVEF, 2D-echocardiography is the best initial test for the ease of the exam, wide availability, low cost, and no ionizing radiation.
  • If 2D-echocardiograpy is not diagnostic, for example, poor acoustic window, ERNA is a good alternative choice.
  • CMR is the gold standard and may be consider for the more accurate assessment of the LVEF and there is a discrepancy between 2D echocardiography and ERNA.

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Correspondence Address:
Ahmed Fathala
Department of Medical Imaging Service, King Faisal Specialist Hospital and Research Center, P. O. Box 3354,Riyadh 11211, MBC 28, Saudi Arabia

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DOI: 10.4103/0971-9784.81570

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