Stress-Cine-MRT zur Primärdiagnostik der koronaren Herzkrankheit

Zusammenfassung

Belastungsuntersuchungen sind einer der wesentlichen Pfeiler der nicht-invasiven Diagnostik der koronaren Herzkrankheit (KHK). Die Stress-Cine-Magnetresonanztomographie (Stress-MRT) beruht wie die Stressechokardiographie auf dem direkten Nachweis ischämieinduzierter Wandbewegungsstörungen. Ihr Einsatz bei kardialen Belastungsuntersuchungen wurde bisher vor allem durch die langen Untersuchungszeiten und die limitierten Überwachungsmöglichkeiten der Patienten eingeschränkt. Erst seit kurzem wurden durch technische Weiterentwicklungen (insbesondere ultraschnelle k-Raum-segmentierte Sequenzen) die wesentlichen Rahmenbedingungen für eine klinisch praktikable kardiale MRT-Belastungsdiagnostik geschaffen. Als Stress-Induktoren können physikalische (Fahrradergometrie) und pharmakologische Belastungsverfahren (β₁-Mimetika [Dobutamin] oder Vasodilatatoren [Dipyridamol, Adenosin]) eingesetzt werden. Insbesondere seit der Etablierung von Hochdosis-Protokollen mit fakultativer Atropingabe wird die Belastung mit Dobutamin bei der Stress-MRT zum Nachweis einer KHK (Sensitivität: 83 - 87 %; Spezifität: 83 - 86 %) von den meisten Arbeitsgruppen favorisiert. Schwerere Komplikationen treten in 0,25 % der Fälle auf. Im direkten Vergleich zeigte sich die Dobutamin-Stress-MRT aufgrund der besseren Bildqualität der Dobutamin-Stressechokardiographie überlegen (Sensitivität: 86,2 % vs. 74,3 %, p < 0,05; Spezifität: 85,7 % vs. 69,8 %, p < 0,05). Die Stress-MRT ist bereits zum jetzigen Zeitpunkt eine realistische - in der Routinediagnostik anwendbare - Alternative zur Stressechokardiographie. Vom Einsatz der Stress-MRT profitieren zur Zeit v. a. Patienten, bei denen aufgrund grundsätzlich schlechter Schallbarkeit mit hoher Wahrscheinlichkeit von nicht oder nur eingeschränkt beurteilbaren stressechokardiographischen Untersuchungen auszugehen ist.

Abstract

Stress testing is the cornerstone in the diagnosis of patients with suspected coronary artery disease (CAD). Stress echocardiography has become a well-established modality for the detection of ischemia-induced wall motion abnormalities. However, display and reliable interpretation of stress echocardiography studies are user-dependent, the test reproducibility is low, and 10 to 15 % of patients yield suboptimal or non-diagnostic images. Due to its high spatial and contrast resolution, MRI is known to permit an accurate determination of left ventricular function and wall thickness at rest. Early stress MRI studies provided promising results with respect to the detection of CAD. However, the clinical impact was limited due to long imaging time and problematic patient monitoring in the MRI environment. Recent technical improvements - namely ultrafast MR image acquisition - led to a significant reduction of imaging time and improved patient safety. Stress can be induced by physical exercise or pharmacologically by administration of a beta₁-agonist (dobutamine) or vasodilatator (dipyridamole and adenosine). The best developed and most promising stress MRI technique is a high-dose dobutamine/atropine stress protocol (10, 20, 30, 40 μg/kg/min; optionally 0.25-mg fractions of atropine up to maximal dose 1 mg). Severe complications (myocardial infarction, ventricular fibrillation and sustained tachycardia, cardiogenic shock) may be expected in 0.25 % of patients. Currently, data of three high-dose dobutamine stress MRI studies are available, revealing a good sensitivity (83 - 87 %) and specificity (83 - 86 %) in the assessment of CAD. The direct comparison between echocardiography and MRI for the detection of stress-induced wall motion abnormalities yielded better results for dobutamine-MRI in terms of sensitivity (86.2 % vs. 74.3 %; p < 0.05) and specificity (85.7 % vs. 69.8 % p < 0.05) as compared to dobutamine stress echocardiography. The superior results of MRI can mainly be explained by the better image quality with sharp delineation of the endocardial and epicardial borders. Currently, stress MRI is already a realistic clinical alternative for the non-invasive assessment of CAD in patients with impaired image quality in echocardiography.

Magnetresonanztomographie - Dobutamin - Dipyridamol - Stressechokardiographie - Koronare Herzerkrankung

Magnetic resonance (MR), cardiac studies - Pharmacological stress - Dobutamine - Dipyridamole - Stress echocardiography - Coronary artery disease

Literatur

• 1 American Heart Association.  Statistical Facts. Dallas, TX. American Heart Association 1996
• 2 Ryan T, Vasey C G, Presti C F, O'Donnell J A, Feigenbaum H, Armstrong W F. Exercise echocardiography: Detection of coronary artery disease in patients with normal left ventricular wall motion at rest.  J Am Coll Cardiol. 1988;  11 993-999
• 3 Mertes H, Erbel R, Nixdorff U, Mohr-Kahaly S, Wölfinger D, Meyer J. Belastungsechokardiographie: Eine sensitive Methode in der Diagnostik der koronaren Herzkrankheit.  Herz. 1991;  16 355-366
• 4 Abouantoun S, Ahnve S, Savvides M, Witztum K, Jensen D, Froelicher V. Can areas of myocardial ischemia be localized by the exercise electrocardiogram? A correlative study with thallium-201 scintigraphy.  Am Heart J. 1984;  108 933-941
• 5 Wann L S, Faris J V, Cildrens R H, Dillon J C, Weyman A E, Feigenbaum H. Exercise cross-sectional echocardiography in ischemic heart disease.  Circulation. 1979;  60 1300-1308
• 6 Nixdorff U, Mohr-Kahaly S, Wagner S, Meyer J. Klinischer Stellenwert der Stressechokardiographie.  Dt Ärtzebl. 1997;  94 A1723-A1728
• 7 Kivelitz D E, Taupitz M, Hamm B. Diagnostic assessment after myokardial infarction: What is the role of magnetic resonance imaging?.  Fortschr Röntgenstr. 1999;  171 349 - 358
• 8 Rominger M B, Bachmann G F, Pabst W, Ricken W W, Dinkel H P, Rau W S. Left ventricular heart volume determination with fast MRI breath holding technique: How different are quantitative heart catheter, quantitative MRI and visual echocardiography?.  Fortschr Röntgenstr. 2000;  172 23-32
• 9 Pennell D J, Underwood S R, EII P J. et al . Dipyridamole magnetic resonance imaging: a comparison with thallium-201 emission tomography.  Br Heart J. 1990;  64 362-369
• 10 Pennell D J, Underwood R S, Manzara C C. et al . Magnetic resonance imaging during dobutamine stress in patients with coronary artery disease.  Am J Cardiol. 1992;  70 34-40
• 11 Baer F M, Smolarz K, Jungehulsing M. et al . Feasibility of high dose dipyridamole magnetic resonance imaging for detection of coronary artery disease and comparison with coronary angiography.  Am J Cardiol. 1992;  69 51
• 12 Nesto R W, Kowalchuk G J. The ischemic cascade: Temporal sequence of hemodynamic, electrocardiographic and symptomatic expressions of ischemia.  Am J Cardiol. 1987;  57 23 C
• 13 Weikl A, Moshage W, Hentschel D, Schittenhelm R, Bachmann K. EKG-Veränderungen durch Einwirkung von statischen Magnetfeldern bei der Kernspintomographie in Magneten der Feldstärke 0,5 bis 4,0 Tesla.  Z Kardiol. 1989;  78 578-586
• 14 Nixdorff U, Wagner S, Erbel R, Weitzel P, Mohr-Kahaly S, Meyer J. Normalwerte für die Dobutamin-Stressechokardiographie.  Dtsch Med Wschr. 1995;  120 1761-1767
• 15 Lieng L H, Pellikka P A, Mahoney D W. et al . Atropine augmentation in dobutamine stress echocardiography: role and incremental value in a clinical practice setting.  J Am Coll Cardiol. 1996;  28 551-557
• 16 Picano E, Mathias W, Pingitore A. et al . Safety and tolerability of dobutamine-atropine stress echocardiography: a prospective, multicentre study.  Lancet. 1994;  344 1190-1192
• 17 Secknus M A, Marvvick T H. Evolution of dobutamine echocardiography protocols and indications: safety and side effects in 3,011 studies over 5 years.  J Am Coll Cardiol. 1997;  29 1234-1240
• 18 Lette J. the Multicenter Dipyridamole Safety Study Investigators . Safety of dipyridamole testing in 73.806 patients: The dipyridamole safety study.  J Nucl Cardiol. 1995;  2 3-12
• 19 Oshinski J N, Ferichs F, Doyle J A. et al .Exercise stress measurements of cardiac performance using an MR compatible cycle ergometer. Proceedings of the Int Soc Magn Reson Med 1997: 900
• 20 Presti T, Armstrong W E, Feigenbaum H. Comparison of echocardiography at peak exercise and after bicycle exercise in evaluation of patients with known or suspected coronary artery disease.  J Am Soc Echocardiogr. 1988;  1 119-126
• 21 Marwick T H, Willemart B, D'Hondt A M. et al . Selection of the optimal nonexercise stress for the evaluation of ischemic regional myocardial dysfunction and malperfusion.  Circulation. 1993;  87 345-354
• 22 Previtali M, Lanzarini L, Ferrario M. et al . Dobutamine versus dipyridamole echocardiography in coronary artery disease.  Circulation. 1991;  83 27-31
• 23 Beleslin B D, Ostojic M, Stepanovic J. et al . Stress echocardiography in the detection of myocardial ischemia: head-to-head comparison of exercise, dobutamine, and dipyridamole tests.  Circulation. 1994;  90 1168-1176
• 24 Ostojic M, Picano E, Beleslin B. et al . Dipyridamole-dobutamine echocardiography: a novel test for the detection of milder forms of coronary artery disease.  J Am Coll Cardiol. 1994;  23 1115-1122
• 25 Dagianti A ;, Penco M, Agati L. et al . Stress echocardiography: comparison of exercise, dipyridamole and dobutamine in and predicting the extent of coronary artery disease.  J Am Coll Cardiol. 1995;  26 18-25
• 26 Salustri A, Fioretti P M, McNeill A J. et al . Pharmacological stress echocardiography in the diagnosis of coronary artery disease and myocardial ischemia: a comparison between dobutamine and dipyridamole.  Eur Heart J. 1992;  13 1356-1362
• 27 Baer F M, Voth E, Theissen P. et al . Coronary artery disease: Findings with GRE MR imaging and To-99mm-methoxyisobutyl-isonitrile SPECT during simultaneous dobutamine stress.  Radiology. 1994;  193 203
• 28 Nagel E, Lehmkuhl H B, Bocksch W. et al . Noninvasive diagnosis of ischemia induced wall motion abnormalities with the use of highdose dobutamine stress-MRI.  Circulation. 1999;  99 763-770
• 29 Hundley W G, Hamilton C A, Thomas M S. et al . Utility of fast cine magnetic resonance imaging and display for the detection of myocardial ischemia in patients not well suited for second harmonic stress echocardiography.  Circulation. 1999;  100 1697-1702
• 30 Jochims M, Schmidt M, Crnac J. et al . Dobutamine stress magnetic resonance imaging: a reliable alternative to stress echocardiography in patients with insufficient image quality.  Eur Heart J. 1999;  20 678
• 31 Geleijnse M L, Fioretti P M, Roelandt J RTC. Methodology, feasibility, safety and diagnostic accuracy of dobutamine stress echocardiography.  J Am Coll Cardiol. 1997;  30 595-606
• 32 Kerber R E. Echocardiography in coronary artery disease. Futura, Mount Kisco, NY 1988
• 33 Schiller N B, Shah P M, Crawford M. et al . Recommendations for quantitation of the left ventricle by two-dimensional echocardiography.  J Am Soc Echo. 1989;  2 358-367
• 34 Hoffmann R, Lethen H, Marvvick T. et al . Analysis of interinstitutional observer agreement in the interpretation of dobutamine stress echocardiograms.  J Am Coll Cardiol. 1996;  27 330-336
• 35 Nagel E, Lehmkuhl H B, Klein C. et al . Einfluss der Bildqualität auf die Genauigkeit der nichtinvasiven Ischämiediagnostik mit der Dobutamin-Stressmagnetresonanztomographie im Vergleich zur Dobutamin-Stressechokardiographie.  Z Kardiol. 1999;  88 622 - 630
• 36 Chin D, Hancock J, Brown A. et al . Improved endocardial definition and evaluation of dobutamine stress echocardiography using second harmonic imaging.  J Am Coll Cardiol. 1998;  31 Suppl A 76A
• 37 Thomas J D, Rubin D N. Tissue harmonic imaging: Why does it work?.  J Am Soc Echocardiogr. 1998;  11 803-808
• 38 van Rugge F P, van der Wall E E, Spanjersberg S J. et al . Magnetic resonance imaging during dobutamine stress for detection and localization of coronary artery disease. Quantitative wall motion analysis using a modiflcation of the centerline method.  Circulation. 1994;  90 127-138
• 39 Zhao S, Croisille P, Janier M. et al . Comparison between qualitative and quantitative wall motion analyses using dipyridamole-stress breath-hold tine magnetic resonance imaging in patients with severe coronary artery stenosis.  Magn Reson Imaging. 1997;  15 891-898
• 40 Bremerich J, Buser P, Bongartz G. et al . Noninvasive stress testing of myocardial ischemia: Comparison of GRE-MRI perfusion and wall motion analysis to 99mTc-MIBI SPECT, relation to coronary angiography.  Eur Radiol. 1997;  7 990-997