The Atherosclerotic Process and Its Relationship to Coronary Blood Flow

  • Dominique Delbeke
  • Philipp A. Kaufmann


Cardiovascular disease is the number one cause of mortality in the United States. Human atherosclerosis is a dynamic process that begins early and progresses throughout life. Cardiac risk factors — smoking tobacco, hypertension (HTN), hypercholesterolemia, diabetes mellitus (DM), or a positive family history of coronary artery disease (CAD) — are known to accelerate the atherosclerotic process that naturally affect all human beings [1]. Atherosclerosis will first cause narrowing of coronary arteries but without inducing ischemia. With progression, coronary stenoses will first affect coronary blood flow reserve (CBFR), which can be detected only with stress testing, before affecting myocardial blood flow (MBF) at rest. Periods of ischemia lasting >40 min cause irreversible injury. If the ischemic period is long enough to cause total necrosis (usually 6–12 h), the infarct is transmural. Chronically ischemic myocardium, in which the blood supply is adequate to preserve viability but not to maintain normal cell function, can result in regional dyssynergy (hibernating myocardium). Revascularization procedures with normal blood flow restoration to this tissue often leads to significant improvement in wall motion, ventricular function, symptomatology, and prognosis [2].


Myocardial Blood Flow Nuclear Cardiology Framingham Risk Score Myocardial Perfusion Scintigraphy Pretest Probability 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.


  1. 1.
    Stary HC (ed) (1999) Atlas of atherosclerosis: progression and regression. Parthenon, New York, NYGoogle Scholar
  2. 2.
    Dilsizian V, Bonow R (1993) Current diagnostic techniques of assessing myocardial viability in patients with hibernating and stunned myocardium. Circulation 87:1–20PubMedCrossRefGoogle Scholar
  3. 3.
    Klocke FJ, Baird MG, Lorell BH et al for the American College of Cardiology; American Heart Association; American Society for Nuclear Cardiology (2003) ACC/AHA/ASNC guidelines for the clinical use of cardiac radionuclide imaging — executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (ACC/AHA/ASNC Committee to Revise the 1995 Guidelines for the Clinical Use of Cardiac Radionuclide Imaging). J Am Coll Cardiol 42:1318–1333PubMedCrossRefGoogle Scholar
  4. 4.
    Brindis AG, Douglas P, Hendel, R et al for the ACCF Appropriateness Criteria Working Group (2005) ACCF/ASNC appropriateness criteria for single-photon emission computed tomography myocardial perfusion imaging (SPECT MPI). J Am Coll Cardiol 46:1587–1605PubMedCrossRefGoogle Scholar
  5. 5.
    Holly TA, Abbott BG, Al-Mallah M et al (2010) ASNC imaging guidelines for nuclear cardiology procedures. J Nucl Cardiol 17:941–973PubMedCrossRefGoogle Scholar
  6. 6.
    Cerqueira MD, Berman DS, Di Carli MF et al (2006) Task Force 5: training in nuclear cardiology. J Am Coll Cardiol 47:898–804PubMedCrossRefGoogle Scholar
  7. 7.
    Budoff MJ, Cohen MC, Garcia MJ et al (2005) ACCF/AHA: Clinical competence on cardiac imaging with computed tomography and magnetic resonance: a report of the American College of Cardiology Foundation/American Heart Association/American College of Physicians Task Force on Clinical Competence and Training. J Am Coll Cardiol 46:383–402PubMedCrossRefGoogle Scholar
  8. 8.
    Deman P, Eckdahl J, Folks R et al (1997) Guidelines for technologist training in nuclear cardiology. J Nucl Cardiol 4:422–425PubMedCrossRefGoogle Scholar
  9. 9.
    Lette J, Tatum JL, Fraser S et al (1995) Safety of dipyridamole testing in 73,806 patients: the multicenter dipyridamole safety study. J Nucl Cardiol 2:3–17PubMedCrossRefGoogle Scholar
  10. 10.
    Abreu A, Mahmarian JJ, Nishimura S et al (1991) Tolerance and safety of pharmacologic coronary vasodilation with adenosine in association with thallium-201 scintigraphy in patients with coronary artery disease. J Am Coll Cardiol 18:730–735PubMedCrossRefGoogle Scholar
  11. 11.
    Cerqueira MD, Verani MS, Schwaiger M et al (1994) Safety profile of adenosine stress perfusion imaging: results from the Adenoscan multicenter trial registry. J Am Coll Cardiol 23:384–390PubMedCrossRefGoogle Scholar
  12. 12.
    Vitola JV, Brambatti JC, Caligaris F et al (2001) Exercise supplementation to dipyridamole prevents hypotension, improves electrocardiogram sensitivity, and increases heart-to liver activity ratio on Tc-99m sestamibi imaging. J Nucl Cardiol 8:652–659PubMedCrossRefGoogle Scholar
  13. 13.
    Elliot MD, Holly TA, Leonard SM, Hendel RC (2000) Impact of an abbreviated adenosine protocol incorporating adjunctive treadmill exercise on adverse effects and image quality in patients undergoing stress myocardial perfusion imaging. J Nucl Cardiol 7:584–589CrossRefGoogle Scholar
  14. 14.
    Samady H, Wackers FJTh, Joska TM et al (2002) Pharmacologic stress perfusion imaging with adenosine: role of simultaneous low-level treadmill exercise. J Nucl Cardiol 9:188–196PubMedCrossRefGoogle Scholar
  15. 15.
    Elhendy A, van Domburg RT, Vantrimpont P et al (2001) Impact of heart transplantation on the safety and feasibility of the dobutamine stress test. J Heart Transplant 20:399–406CrossRefGoogle Scholar
  16. 16.
    Iskandrian AE, Bateman TM, Belardinelli L et al (2007) Adenosine versus regadenoson comparative evaluation in myocardial perfusion imaging: results of the advance phase III multi-center international trial. J Nucl Cardiol 14:645–658PubMedCrossRefGoogle Scholar
  17. 17.
    Leaker BR, O’Connor B, Hansel TT et al (2008) Safety of regadenoson, an adenosine A2A receptor agonist for myocardial perfusion imaging, in mild asthma and moderate asthma patients: a randomized, double-blind, placebo-controlled trials. J Nucl Cardiol 15:329–336PubMedCrossRefGoogle Scholar
  18. 18.
    Grundy SM, Becker D, Clark LT et al (2002) NCEP (National Cholesterol Education Program) Expert Panel on ATP III. Circulation 106:31–43CrossRefGoogle Scholar
  19. 19.
    Shaw LJ, Berman DS, Bax JJ et al (2005) Complementary roles of nuclear cardiology and cardiac CT in the current healthcare environment. J Nuc Cardiol 12:131–142CrossRefGoogle Scholar
  20. 20.
    Diamond GA, Forrester JS (1979) Analysis of probability as an aid in the clinical diagnosis of coronary artery disease. N Engl J Med 300:1350–1358PubMedCrossRefGoogle Scholar
  21. 21.
    Hamilton GW, Trobaugh G, Richie JC et al (1978) Myocardial imaging with 201T1: an analysis of clinical usefulness based on Bayes’ theorem. Semin Nucl Med 8:358PubMedCrossRefGoogle Scholar
  22. 22.
    Goldstein JA, Gallagher MJ, O’Neill WW et al (2007) A randomized controlled trial of multi-slice coronary computed tomography for evaluation of acute chest pain. J Am Coll Cardiol 49:863–871PubMedCrossRefGoogle Scholar
  23. 23.
    Bateman TM, Heller GV, McGhie AI et al (2006) Diagnostic accuracy of rest/stress ECG-gated Rb-82 myocardial perfusion PET: comparison with ECG-gated Tc-99m sestamibi SPECT. J Nucl Cardiol 13:24–33PubMedCrossRefGoogle Scholar
  24. 24.
    Sampson UK, Dorbala S, Limaye A et al (2007) Diagnostic accuracy of rubidium-82 myocardial perfusion imaging with hybrid positron emission tomography/computed tomography in the detection of coronary artery disease. J Am Coll Cardiol 49:1052–1058PubMedCrossRefGoogle Scholar
  25. 25.
    Dorbala S, Vangala D, Sampson U et al (2007) Value of vasodilator left ventricular ejection fraction reserve in evaluating the magnitude of myocardium at risk and the extent of angiographic coronary artery disease: a 82Rb PET/CT study. J Nucl Med 48:349–358PubMedGoogle Scholar
  26. 26.
    Abidov A, Germano G, Berman DS (2007) Transient ischemic dilation ratio: a universal high-risk diagnostic marker in myocardial perfusion imaging. J Nucl Cardiol 14:497–500PubMedCrossRefGoogle Scholar
  27. 27.
    Hachamovitch R, Berman DS, Shaw LJ et al (1998) Incremental prognostic value of myocardial perfusion single photon emission computed tomography for the prediction of cardiac death: differential stratification for risk of cardiac death and myocardial infarction. Circulation 97:535–543PubMedCrossRefGoogle Scholar
  28. 28.
    Hachamovitch R, Hayes SW, Friedman JD et al (2003) Comparison of the short-term survival benefit associated with revascularization compared with medical therapy in patients with no prior coronary artery disease undergoing stress myocardial perfusion single photon emission computed tomography. Circulation 107:2900–2907PubMedCrossRefGoogle Scholar
  29. 29.
    Sharir T, Germano G, Kang X et al (2001) Prediction of myocardial infarction versus cardiac death by gated myocardial perfusion SPECT: risk stratification by the amount of stress-induced ischemia and the poststress ejection fraction. J Nucl Med 42:831–837PubMedGoogle Scholar
  30. 30.
    Udelson JE, Beshansky JR, Ballin DS et al (2002) Myocardial perfusion imaging for evaluation and triage of patients with suspected acute cardiac ischemia. A randomized controlled trial. JAMA 288:2693–2700PubMedCrossRefGoogle Scholar
  31. 31.
    Berman DS, Boden WE, O’Rourke RA et al (2007) Optimal medical therapy with or without PCI for stable coronary disease. N Engl J Med 356:1–14CrossRefGoogle Scholar
  32. 32.
    Slart RH, Bax JJ, van Veldhuisen DJ et al (2006) Imaging techniques in nuclear cardiology for the assessment of myocardial viability. Int J Cardiovasc Imaging 22:63–80PubMedCrossRefGoogle Scholar
  33. 33.
    Bax JJ, Cornel JH, Visser FC et al (1998) Comparison of fluorine-18-FDG with rest-redistribution thallium-201 SPECT to delineate viable myocardium and predict functional recovery after revascularization. J Nucl Med 39:1481–1486PubMedGoogle Scholar
  34. 34.
    Hendel RC, Corbett JR, Cullom SJ et al (2002) The value and practice of attenuation correction for myocardial perfusion SPECT imaging: A joint position statement from the American Society of Nuclear Cardiology and the Society of Nuclear Medicine. J Nucl Med 43:273–280Google Scholar
  35. 35.
    Di Carli MF, Hachamovitch R (2007) New technology for non-invasive evaluation of coronary artery disease. Circulation 115:1464–1480PubMedCrossRefGoogle Scholar
  36. 36.
    Greenland P, Bonow RO, Brundage BH et al (2007) Clinical expert consensus document on coronary artery calcium scoring by computed tomography in global cardiovascular risk assessment and in evaluation of patients with chest pain. Circulation 23:403–426Google Scholar
  37. 37.
    Budoff MJ, Achenbach S, Blumenthal RS et al (2006) Assessment of coronary artery disease by cardiac computed tomography: a scientific statement from the AHA Committee on Cardiovascular Radiology and Intervention, and Committee on Cardiac Imaging, Council on Clinical Cardiology. Circulation 114:1761–1791PubMedCrossRefGoogle Scholar
  38. 38.
    Hendel RC, Patel MR, Kramer CM et al (2006) ACCF/ACR/SCCT/SCMR/ASNC/NASCI/SCAI/SIR 2006 appropriateness criteria for cardiac computed tomography and cardiac magnetic resonance imaging: a report of the American College of Cardiology Foundation Quality Strategic Directions Committee Appropriateness Criteria Working Group, American College of Radiology, Society of Cardiovascular Computed Tomography, Society for Cardiovascular Magnetic Resonance, American Society of Nuclear Cardiology, North American Society for Cardiac Imaging, Society for Cardiovascular Angiography and Interventions, and Society of Interventional Radiology. J Am Coll Cardiol 48:1475–1497PubMedCrossRefGoogle Scholar
  39. 39.
    Flotats A, Knuuti J, Gutberlet M et al on behalf of the Cardiovascular Committee of the EANM, the ESCR and the ECNC (2011) Hybrid cardiac imaging: SPECT/CT and PET/CT. A joint position statement by the European Association of Nuclear Medicine (EANM), the European Society of Cardiac Radiology (ESCR) and the European Council of Nuclear Cardiology (ECNC). Eur J Nucl Med Mol Imaging 38:201–212PubMedCrossRefGoogle Scholar
  40. 40.
    Limacher MC, Douglas PS, Germano G et al (1998) ACC expert consensus document. Radiation safety in the practice of cardiology. J Am Coll Cardiol 31:892–913PubMedCrossRefGoogle Scholar
  41. 41.
    Thompson RC, Cullom SJ (2006) Issues regarding dosage of cardiac nuclear and radiography procedures. J Nucl Cardiol 13:19–23PubMedCrossRefGoogle Scholar
  42. 42.
    Stabin MG (2008) Radiopharmaceuticals for nuclear cardiology: radiation dosimetry, uncertainties, and risk. J Nucl Med 49:1555–1563PubMedCrossRefGoogle Scholar
  43. 43.
    Mettler FA Jr, Bhargavan M, Thomadsen BR et al (2008) Nuclear medicine exposure in the United States, 2005–2007: preliminary results. Semin Nucl Med 38:384–391PubMedCrossRefGoogle Scholar
  44. 44.
    Patton JA, Slomka PJ, Germano G, Berman DS (2007) Recent technologic advances in nuclear cardiology. J Nucl Cardiol 14:501–513PubMedCrossRefGoogle Scholar
  45. 45.
    Bateman TM, Heller GV, McGhie AI et al (2009) Multicenter investigation comparing a highly efficient half-time stress-only attenuation correction approach against standard rest-stress Tc-99m SPECT imaging. J Nucl Cardiol 16:726–735PubMedCrossRefGoogle Scholar
  46. 46.
    Senthamizhchelvan S, Bravo PE, Esaias C et al (2010) Human biodistribution and radiation dosimetry of 82Rb. J Nucl Med 51:1592–1599PubMedCrossRefGoogle Scholar
  47. 47.
    Pazhenkottil AP, Herzog BA, Husmann L et al (2010) Non-invasive assessment of coronary artery disease with CT coronary angiography and SPECT: a novel dose-saving fast-track algorithm. Eur J Nucl Med Mol Imaging 37:522–527PubMedCrossRefGoogle Scholar

Copyright information

© Springer-Verlag Italia 2011

Authors and Affiliations

  • Dominique Delbeke
    • 1
  • Philipp A. Kaufmann
    • 2
  1. 1.Department of Radiology and Radiological SciencesVanderbilt University Medical CenterNashvilleUSA
  2. 2.University Hospital of ZurichZurichSwitzerland

Personalised recommendations