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Rofo 2002; 174(5): 605-613
DOI: 10.1055/s-2002-28277
Herz
Originalarbeit
© Georg Thieme Verlag Stuttgart · New York

Stress-Cine-MRT zur Primärdiagnostik der koronaren Herzkrankheit

Stress cine MRI for detection of coronary artery diseaseT.  Sommer1 , U.  Hofer1 , H.  Omran2 , H.  Schild1
  • 1Radiologische Universitätsklinik Bonn
  • 2Medizinische Universitätsklinik II Bonn
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Publication History

Publication Date:
07 May 2002 (online)

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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.

Schlüsselwörter

Magnetresonanztomographie - Dobutamin - Dipyridamol - Stressechokardiographie - Koronare Herzerkrankung

Key words

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

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Priv.-Doz. Dr. T. Sommer

Radiologische Universitätsklinik Bonn

Sigmund-Freud-Str. 25

53127 Bonn

Email: t.sommer@uni-bonn.de