Figure 3.

Three examples of CMR, SPECT, and angiographic findings

(A) Stress perfusion CMR shows inducible hypoperfusion (ischaemia) in the septum and anterior wall (arrow shows dark area of hypoperfusion), SPECT is concordant (arrows show lower signal counts during stress), indicating anteroseptal inducible ischaemia, and angiography confirms a stenosis (arrow) in the left anterior descending artery. (B) Late gadolinium-enhanced CMR (arrow shows hyperenhancement in the inferior wall) and SPECT (fixed defect; arrows show comparable inferior defect at rest and stress) are concordant, showing a transmural inferior myocardial infarct with the corresponding right coronary artery chronic total occlusion (arrow) seen at angiography. (C) Late gadolinium-enhanced CMR shows subendocardial inferior infarction (arrow), SPECT was reported as normal (no wall motion abnormality), and the angiogram shows coronary atheroma but no clinically significant stenosis (or occlusion). As per study protocol, CMR in this patient was classified as a false positive, showing the potential limitations of angiography as a reference test for the detection of coronary heart disease. The case also shows that SPECT can miss small subendocardial infarcts. CMR=cardiovascular magnetic resonance. SPECT=single-photon emission computed tomography.