Author + information
- Nuno Bettencourt, MD∗ ( and )
- Eike Nagel, MD, PhD
- ↵∗Cardiology Department, Centro Hospitalar de Vila Nova de Gaia/Espinho EPE, Rua Conceição Fernandes, 4434-502 Vila Nova de Gaia, Portugal
We are thankful for the interest from Drs. Bauml and Farzaneh-Far in our paper (1) and the opportunity to provide further detail of our research. The point highlighted merits discussion and focuses on an interesting finding. Considering the presence of a previous myocardial infarction assessed by late gadolinium enhancement (LGE) as a marker of significant coronary artery disease (CAD) makes sense for establishing the correct diagnosis. (2). From the viewpoint of diagnostic accuracy, it has the advantage of avoiding “false negatives” in patients with infarctions subtended by occluded or severely stenotic vessels while at the same time it has the disadvantage of increasing the rate of “false positives” in the setting of ischemic scar with nonobstructive coronaries (e.g., due to thrombus with spontaneous resolution). However, more important than establishing the correct diagnosis is to inform on the best management strategy (3) a concept that is vastly underrepresented in the imaging literature. As such, it is more important to detect ischemia, rather than coronary artery stenoses, as a stenotic vessel supplying an infarcted territory without remaining ischemia does not require revascularization. One of the main components for the success of fractional flow reserve is based on this understanding, despite the fact that fractional flow reserve does not account for the ischemic burden.
In our study population, there was 1 additional false positive patient without reduction of the false negatives when scar was added as a criterion for significant CAD (Table 1). While this observation further supports the noninferiority of an integrated computed tomography protocol (including angiography and perfusion) to a cardiac magnetic resonance myocardial perfusion imaging/LGE approach, it is important to highlight the importance of scar assessment in this group of patients. Even though LGE does not improve the accuracy of perfusion for the detection of significant CAD, it does have important prognostic implications (4) and may impact patient management.
- American College of Cardiology Foundation
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