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Coronary artery disease is the leading cause of ischemic cardiomyopathy. Approximately half of the patients with coronary artery disease can have dysfunctional hibernating myocardium that is potentially reversible with restoration of blood flow. Earlier identification of these areas can have profound prognostic implications. This activity reviews the role of both invasive and noninvasive imaging techniques in the evaluation of coronary artery disease. Objectives: Identify the role of infarct-avid imaging techniques in the evaluation of coronary artery disease. Compare the indications of invasive and noninvasive imaging techniques in evaluating coronary artery disease. Determine additional information that can be obtained from infarct-avid imaging techniques that can further guide diagnostic testing and therapeutic strategy. Communicate with the interprofessional team to determine different characteristics and limitations of individual infarct-avid imaging techniques. Access free multiple choice questions on this topic.

Coronary artery disease is the leading cause of ischemic cardiomyopathy. Impairment in left ventricular dysfunction can result from a spectrum of myocardial injury, including ischemia and myocardial necrosis, causing progressive tissue remodeling.[1] Approximately half of the patients with coronary artery disease can have dysfunctional hibernating myocardium that is potentially reversible with restoration of blood flow. Earlier identification of these areas can have profound prognostic implications.[2] Most noninvasive imaging techniques can assess wall motion abnormalities and function, such as an echocardiogram, coronary computed tomography angiography (CCTA), magnetic resonance imaging (MRI), and nuclear studies. However, each technique has distinct characteristics that can help decide which study should be performed based on the clinical indication.An echocardiogram is often the initial study of choice for assessing cardiac function in critically ill or unstable patients, as it can be conveniently performed at the bedside and is not associated with radiation. Thus, it can be safely used in both pregnant and pediatric patients. CCTA is the best noninvasive technique to evaluate anomalous vessels, luminal irregularities, and stenosis of the coronary vasculature.[3] Cardiac magnetic resonance (CMR) and nuclear studies can better characterize abnormalities within myocardial tissue, such as scar formation or infiltrative processes. Additionally, myocardial perfusion imaging (MPI) with single-photon emission computed tomography (SPECT) and positron emission tomography (PET) provide information regarding tissue viability and perfusion defects and can further guide treatment. Invasive coronary angiography serves as a diagnostic and therapeutic assessment tool to restore vascularization and potentially improve ventricular dysfunction.

Complications are typically associated with invasive techniques and the use of contrast material. Although rarely seen with gadolinium, the theoretical risk of nephrogenic systemic fibrosis remains a concern, especially in patients with poor kidney function. Both CCTA and coronary angiography with catheterization must be done with caution in patients with severely reduced renal function, given the use of contrast, and both imaging techniques involve radiation exposure. Despite cardiac catheterization being the gold standard imaging modality in the evaluation of coronary artery disease, risks include bleeding, infection, retroperitoneal hemorrhage, dysrhythmias, pseudoaneurysms, coronary artery dissection, tamponade, pneumothorax, and death.[14]