Journal of Cardiovascular Computed Tomography 14 (2020) 87–100

Contents lists available at ScienceDirect

Journal of Cardiovascular Computed Tomography

journal homepage: www.elsevier.com/locate/jcct

Society of cardiovascular computed tomography expert consensus document T

on myocardial computed tomography perfusion imaging
Amit R. Patela,∗, Fabian Bambergc, Kelley Branchd, Patricia Carrascosae, Marcus Chenf,
Ricardo C. Curyg, Brian Ghoshhajrah, Brian Koi, Koen Niemanj, Francesca Pugliesek,
Joseph Schoepfl, Ron Blanksteinb,∗∗
a
University of Chicago, USA
b
Brigham and Women's Hospital, USA
c
University of Tuebingen, Germany
d
University of Washington, USA
e
Diagnostico Maipu, Argentina
f
National Institutes of Health/NHLBI, USA
g
Radiology Associates of South Florida, USA
h
Massachusetts General Hospital, USA
i
Monash Heart, Australia
j
Stanford University, USA
k
Queen Mary University of London, UK
l
Medical University of South Carolina, USA

1. Introduction angiography (ICA), positron emission tomography (PET), and invasive

Advances in X-ray computed tomography (CT) over the past 20
years have enabled non-invasive imaging of the coronary arteries, as
well as cardiac structure and function. Coronary computed tomography
angiography (CTA) has emerged as an accurate non-invasive imaging
modality for identifying the anatomic severity of coronary stenoses.1–3
Similar to other anatomic coronary imaging, coronary CTA alone has
been limited in its ability to define the hemodynamic significance of
coronary stenoses.4 Since the identification of the presence and severity
of ischemia are important parameters for selecting between invasive
and medical management of coronary artery disease,5–7 the assessment
of both coronary anatomy and myocardial perfusion is needed in some
clinical scenarios.
The development of X-ray CT-based myocardial perfusion imaging
to determine myocardial ischemia began in the late 1980s. Early in-
vestigators used electron beam computed tomography and a fast mul-
tislice CT scanning platform to perform quantitative myocardial per-
fusion imaging with good results.8,9 However, the introduction of
multidetector CT and the proven feasibility of coronary CTA over 10
years ago10–13 also allowed for development and refinement of myo-
cardial CT perfusion (CTP) imaging.4,14–16 In single center studies,
myocardial CTP imaging has demonstrated high accuracy when com-
pared with single photon emission computed tomography (SPECT),
cardiovascular magnetic resonance (CMR), invasive coronary
fractional flow reserve (FFR).4,14,17–25 Multicenter studies have also
established the accuracy of myocardial CTP with coronary CTA.26,27
These studies suggest that CTP is particularly accurate when interpreted
in the context of coronary CTA findings.
Currently, there is large body of evidence that establishes myo-
cardial CTP diagnostic accuracy and incremental value over coronary
CTA.28 However, an important limitation to myocardial CTP im-
plementation is the heterogeneity within the literature of pharmaco-
logic stress agents, imaging sequences, scanner types, acquisition pro-
tocols, post-processing, and interpretation of CTP results. Clinical
adoption of myocardial CTP is further hindered by the absence of expert
consensus regarding when and how CTP should be performed. The goal
of this document is to bring together international experts in myo-
cardial CTP imaging to provide a consensus document that can be used
as a resource for clinical implementation, resource allocation, and fu-
ture investigations.
2. General overview of myocardial CTP, patient selection, and
logistics
Myocardial CTP imaging is the contrast enhanced imaging of
myocardial perfusion using qualitative, semi-quantitative, or quantita-
tive methods. Myocardial CTP imaging may be performed at rest and
during pharmacologically induced stress. An additional acquisition can

∗
Corresponding author.
∗∗
Corresponding author.
E-mail addresses: amitpatel@uchicago.edu (A.R. Patel), RBLANKSTEIN@bwh.harvard.edu (R. Blankstein).

https://doi.org/10.1016/j.jcct.2019.10.003
Received 4 October 2019; Accepted 15 October 2019
Available online 11 December 2019
1934-5925/ © 2020 Published by Elsevier Inc. on behalf of Society of Cardiovascular Computed Tomography
A.R. Patel, et al.
be performed 5–10 minutes after vascular contrast washout to detect
myocardial scar. The two primary methods of acquisition are static CTP
and dynamic CTP. Static CTP, which has been more extensively studied,
involves acquisition of a single image during an infusion of iodinated
contrast to allow qualitative and/or semi-quantitative CTP assessments.
Dual energy CTP is another approach to performing static CTP, which is
less widely used, but utilizes different energy photons to better visualize
iodine contrast within the myocardium. Dynamic CTP imaging involves
acquisition of multiple data sets during the first pass of iodinated
contrast from the coronary arteries into the myocardium. Dynamic CTP
allows for a qualitative, semi-quantitative, as well as fully quantitative
assessment of myocardial perfusion.
Regardless of CTP acquisition mode, patient selection is of utmost
importance. Coronary CTA alone has a very high negative predictive
value to exclude myocardial ischemia in the presence of no CAD or a
non-obstructive stenosis (≤50% severity).4,29–33 Therefore, selection of
a myocardial CTP protocol should generally be reserved for situations
where the determination of the presence or absence of ischemia can be
helpful such as in the presence of coronary artery stenoses of unknown
hemodynamic significance, severe coronary calcification, or coronary
stents.34,35 In the setting of an uninterpretable coronary segment from
any cause, myocardial CTP can improve diagnostic accuracy for both
stenosis and ischemia.36,37 While it is conceivable that patients who
have a higher risk of obstructive CAD are more likely to benefit from
CTP, models to calculate the probability of obstructive CAD are not
widely used and such models often over-estimate the probability of
obstructive disease.38,116
If CTP is used to evaluate for myocardial ischemia, pharmacologic
stress is required. Resting myocardial blood flow is only decreased by
the most severe stenosis, and can be difficult to differentiate from
myocardial infarction, making the use of rest CTP alone non-specific for
ischemia.39,40
Although stress CTP is safe, there are some circumstances where it
should avoided altogether or only used with caution. Absolute and re-
lative CTP contraindications are listed in Table 1.
Summary: We recommend that myocardial CTP may be added to
coronary CTA when patients are at high atherosclerotic risk for ob-
structive coronary artery disease, including those with prior coronary
intervention or significant calcification, or when there is a stenosis of
indeterminate functional significance. In such cases, myocardial CTP is
recommended if knowledge regarding the presence and severity of
ischemia would impact patient management and CTP is feasible.
2.1. Stress CTP procedure logistics
Myocardial CTP imaging with pharmacologic stress testing requires
supervision by a trained medical provider who is experienced in the
administration of pharmacologic stress agents and stress testing. These
clinicians should also be trained in dealing with emergencies related to
contrast injection and vasodilator stress testing. Proper resuscitative
equipment such as a code cart, defibrillator with transcutaneous pacing
capabilities, aminophylline as a reversal agent, bronchodilator therapy,
beta-blockers, sublingual nitroglycerin, and epinephrine and di-
phenhydramine should be available in the immediate vicinity.
Prior to starting the study, a focused patient history and physical
exam, review or performance of a 12-lead ECG, and informed consent
are required to determine suitability of stress testing, similar to other
stress testing guidelines (39,41,42). Appropriate intravenous access
should then be obtained, typically a 20 gauge or larger IV that can
handle the high flows required for contrast injection. During the ad-
ministration of the pharmacologic stress agent, continuous heart rate/
rhythm monitoring and intermittent blood pressure monitoring are
required. Continuous 12-lead ECG monitoring may be performed using
radiolucent electrodes and leads. Alternatively, 12-lead ECG mon-
itoring can be interrupted during scan acquisition while continuous
rhythm is still being recorded and monitored by the scanner console.
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Journal of Cardiovascular Computed Tomography 14 (2020) 87–100
Upon the completion of imaging, a 12 lead ECG should be performed to
ensure there are no significant changes from baseline suggestive of post-
stress myocardial ischemia or injury.
2.2. The use of pharmacologic stress agents, aminophylline and
nitroglycerin
Myocardial CTP stress testing uses only vasodilator stress agents at
present. Exercise and dobutamine are not practical options for CTP due
to the elevated heart rates that would preclude diagnostic imaging with
most currently available CT platforms. While there are no agents ap-
proved for myocardial CTP, adenosine, dipyridamole, and regadenoson
are FDA approved for radionuclide myocardial perfusion imaging.
Therefore, their use in CTP imaging is off-label. These agents, their
actions and adverse reactions have been extensively reviewed else-
where.41 Specific considerations for vasodilator stress CTP include the
need for two IV's for both continuous infusion of adenosine and contrast
injection, while regadenoson and dipyridamole require only one IV for
alternating injections. A potential disadvantage of regadenoson is the
higher heart rate compared with other vasodilators, which may lead to
more motion artifacts during CTP acquisition. However, regadenoson
tends to be better tolerated and has been tested in single center CTP
studies43–45 and a randomized diagnostic accuracy study that compared
CTP and SPECT myocardial perfusion imaging.26 Overall, regadenoson
was similarly tolerated in regards to adverse events between CTP and
SPECT imaging.
Nitroglycerin is commonly used prior to coronary CTA to dilate the
coronary arteries and improve coronary artery visualization. Since it is
also a vasodilator, simultaneous administration of nitroglycerin and a
vasodilator stress agent can lead to hypotension. A 10–20 minute delay
between the administration of the two agents is recommended to avoid
hypotension. Adequate preload will also decrease the risk of hypoten-
sion. The mean elimination half-life of nitroglycerin is 2–3 minutes.
2.3. CT contrast agents
In general, during myocardial CTP, images are acquired during the
transit of contrast from the coronary arteries to the myocardium.
Because iodinated contrast attenuates x-rays proportionally to the
concentration of iodine, hypoattenuated myocardial areas typically
represent regions with low blood flow, or hypoperfusion. Typically,
50–70ml of iodinated contrast is injected at a rate of 5–6 ml/sec. A
saline bolus (40–50ml) following the contrast bolus with the same in-
jection rate is recommended to assist with contrast delivery to the
myocardium. Patients should be warned and educated about the ‘hot
flash’ sensation caused by contrast injection. This sensation can be
uncomfortable and cause breathing or patient movement that in turn
leads to motion artifacts and deterioration of image quality.
3. CTP imaging strategies overview
Myocardial CT perfusion protocols typically include a rest and a
stress CT scan. The rest portion of the scan allows for assessment of the
coronary anatomy in addition to rest myocardial perfusion, thus rest
images should be acquired according to coronary CTA performance and
acquisition guidelines46 and include the use of beta-blockers and ni-
trates. However, the optimal sequence of scans (rest first versus stress
first) has not been determined and either sequence has advantages and
disadvantages. When stress CT imaging is performed first, the myo-
cardium does not have residual contrast in the myocardium from an
earlier contrast injection potentially making it easier to detect ischemia.
In addition, beta-blocker administration may potentially lead to some
underestimation of the ischemic burden, and a stress-first acquisition
will allow for delay of beta-blocker administration until after the stress
acquisition has been performed. Alternatively, if rest coronary CT an-
giography acquisition is evaluated first (e.g. prior to stress), patients
A.R. Patel, et al.
Table 1
Absolute and relative contraindications to pharmacologic stress myocardial CT perfusion.
without an obstructive or questionable coronary stenosis would avoid
stress CT perfusion. However, areas of myocardial infarction may have
delayed contrast enhancement which can potentially be misinterpreted
as “normally perfused” myocardium on the stress CTP images. Neither
sequence of testing has been shown to be superior. Regardless, delaying
10–20 minutes between the rest and stress CT acquisitions is re-
commended to minimize myocardial contrast agent contamination and
to eliminate the effects of pharmacologic stress or nitroglycerin ad-
ministration.
Summary: Our committee suggests assessment of factors that would
impair exclusion of obstructive CAD on coronary CTA (e.g. significant
coronary calcium or known CAD) prior to decision to perform CTP.
Those patients with known significant coronary disease or severe
amount of CAC may undergo stress myocardial perfusion imaging first;
whereas, patients who lack the above features may undergo coronary
CTA first (Fig. 1). The routine use of coronary calcium scoring prior to
stress or resting imaging has been tested and compared against standard
of care in a prospective randomized trial and may be a practical, cost-
effective approach to design a patient-specific imaging protocol.47 The
optimal order of a comprehensive CT perfusion study has not been
determined and is a topic of debate.
4. CTP image acquisition
CTP image acquisition is most commonly performed using either
static, dynamic, or dual energy approach. Discussion of each of the
acquisition modalities is described in detail below and summarized in
Table 2.
4.1. Static CTP image acquisition
Static CTP refers to imaging all or portions of the left ventricular
myocardium during a single period in time as the contrast transits the
myocardium. This method uses retrospective ECG-gating (most often
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Journal of Cardiovascular Computed Tomography 14 (2020) 87–100
with 64 detector scanners) or prospective ECG-triggering to ensure
imaging during specific cardiac phases. Static CTP provides a qualita-
tive or semi-quantitative assessment of myocardial perfusion.14,18,48,117
Conveniently, every coronary CTA is a resting static CTP study. Several
studies have demonstrated that a resting CTP has a high sensitivity and
specificity for the detection of prior myocardial infarction ranging from
77 to 91% and 79–97%, respectively compared with the reference
standard MRI.49–53
Static stress myocardial CTP imaging has been well validated for the
detection of coronary stenosis and myocardial ischemia compared to
various reference standards including pre-clinical validation, invasive
coronary angiography (ICA), single photon emission computed tomo-
graphy (SPECT), magnetic resonance perfusion, and fractional flow
reserve.4,14,15,19,20,117 Advantages of static CTP are its relative simpli-
city of image acquisition, reduced radiation dose, and ease of image
interpretation. Disadvantages include the potential of imaging myo-
cardial contrast off peak enhancement, imaging different myocardial
regions at different time points during CT table movement, presence of
imaging artifacts, and limitations of only qualitative or semi-quantita-
tive ischemia assessment.
4.1.1. ECG-gating strategy
To date, there is no definitive data available to provide guidance on
whether prospective or retrospective ECG gating is preferred for all
patients. The consensus of this committee is that retrospective ECG
gating is favored when smaller z-axis detectors (<8 cm) are utilized to
allow for whole heart coverage in order to reduce artifacts at the
transition zones. Alternatively, prospective ECG triggering is favored
for large Z-axis coverage scanners (≥8 cm) and if the phase acquisition
window can be widened to allow for the acquisition of additional car-
diac phases (i.e. at least 20% of the RR interval). There is currently no
definitive data to recommend the optimal portion of the cardiac cycle to
acquire images. CTA is generally imaged at 65–75% of the R to R in-
terval relative cardiac motion quiescence, or “diastasis”. As the heart
A.R. Patel, et al. Journal of Cardiovascular Computed Tomography 14 (2020) 87–100

Fig. 1. Comparison of CTP acquisition protocols.

rate increases, such as during the administration of a pharmacological
stressor, diastasis becomes shorter and occurs later in the cardiac cycle.
In heart rates over 80 beats per minute, the phase of relative cardiac
quiescence may occur during end-systole (approximately 30–50% of the
R to R interval). The systolic phase may be preferred at higher heart
rates due to a shorter and more stable duration of about 200 msec and it
may be less affected by extrasystolic events. In addition, the in-
traventricular amount of contrast is lower compared with the diastolic
phase, which may reduce beam-hardening artifacts and fluctuations in
myocardial CTP measurements.54,55
There is no consensus about whether imaging should be performed
at end-systole or during diastole although most larger trials to date have
selected diastole. When performing stress CTP, a multiphase acquisition
which includes phases from both systole and diastole can be considered
so that the phase with the least amount of artifact can be selected for
analysis retrospectively.
4.1.2. Contrast timing
Optimal CTP contrast timing is determined manually by contrast
timing bolus or using an automated bolus-tracking algorithm.56 If an
automated bolus-tracking algorithm is utilized, a region of interest
should be defined in either the proximal-ascending or mid-descending
thoracic aorta. The automated trigger should be set to a Hounsfield Unit
(HU) threshold that is ∼80-100HU above the baseline HU of the re-
ference area immediately prior to the contrast injection. After the
scanner is triggered, a short pause (∼5 seconds) is required to allow for
breath-hold instructions to be given. Contrast dose and flow rate is ty-
pically ∼60–70ml injected at 5–6ml/sec. Higher doses of contrast may
be required if a single source 64 slice CT scanner is being used. Imaging is
performed during suspended breathing after peak hyperemia is achieved.
4.1.3. Static CTP minimum scanner requirements
Static CTP imaging requires a CT system capable of acquiring high
spatial resolution images of the entire heart within a short time interval
while patients are holding their breath. This includes virtually all
contemporary 64 slice or greater CT scanners. The temporal resolution
of a CT scan is determined by the time required to acquire the data for
reconstruction of a single transverse section or “slice”. The speed of
gantry rotation is one of the primary determinants of the temporal re-
solution of the CT scan. In CTP, high temporal resolution minimizes
motion artifacts related to a fast heart rate or cardiac contractility that
typically occurs during the administration of a pharmacological
stressor. The minimum gantry rotation time on current generation
scanners (the time required to complete a 360° rotation) is between 250
and 400 ms, depending on the manufacturer and model. Software and
hardware improvements have further increased temporal resolution.
The routine use of half-scan reconstruction results in an effective tem-
poral resolution of approximately one half the time required for the
typical 360° CT rotation, or a reduction to approximately 125–200 ms
per rotation. Dual-source CT scanners equipped with 2 sets of x-ray
sources and detectors offset by ∼90° from each other achieve temporal
resolution of approximately 65 ms. Disadvantages of partial- or half-
scan reconstructions are decreases in the stability of Hounsfield units
within the images due to geometrical and misregistration artifacts.
Hybrid reconstruction protocols utilizing a combination of half-scan
data for image detail and full-scan (360°) data for contrast resolution

Table 2
Comparison of CT perfusion imaging modalities.
Imaging Modality Description Advantages Disadvantages

Static CT perfusion Single image taken at peak myocardial
perfusion to visualize hypoattenutation
(hypoperfusion)
Dynamic CT perfusion Repeated images over time to create
time attenuation curves (TAC's)
Dual Energy CT Separate energy X-ray beams used to
perfusion distinguish myocardium, contrast
attenuation, and other structures
• Technically simple
• Can use CCTA images for rest CTP
• Low radiation exposure
• Semiquantitative myocardial blood flow (MBF)
and volume (MBV) assessment possible
• Modeled, fully quantitative myocardial blood
flow (ml/min/g) assessment possible
• Potential
ischemia
to detect balanced and microvascular
• Higher contrast differentiation than other CTP
modalities
• Beam hardening correction possible
• Additional quantification approaches possible
• Qualitative to semiquantitative analyses only
• Timing of CTP acquisition critical
• Need normal segment to identify abnormal perfusion
• CTP artifacts, such as beam hardening, common
• Increased scanner hardware requirements
• Lower detector systems may require shuttle mode
• CTP artifacts common
• Higher radiation exposure when compared to static CTP
• Additional software requirements
• Specific scanner hardware requirements
• Additional software requirements

90
A.R. Patel, et al.
Table 3
Approaches for assessment and quantification of myocardial perfusion.
CTP Measure Description
Static CTP
Qualitative Visual analysis of perfusion defects (fixed vs
reversible, transmural vs endocardial)
Transmyocardial perfusion ratio (TPR) Ratio of endocardial to epicardial attenuation.
Dynamic CTP
Qualitative Visual analysis of transit of contrast over time
Myocardial Perfusion Reserve Index Ratio of stress-over-rest myocardial peak
attenuation or upslope of myocardial attenuation
curves normalized to the corresponding arterial
TAC parameter.
Quantitative myocardial blood flow Modeled calculation of absolute MBF or MBV from
(MBF) or myocardial blood volume arterial and myocardial time attenuation curves
(MBV)
may provide an advantage.54 The high, nearly isotropic, spatial re-
solution with most modern scanner are less important for visualizing
perfusion defects in the myocardium as discussed later in the CTP re-
construction methods.
4.2. Dynamic CTP image acquisition
Dynamic CT perfusion imaging refers to the imaging of myocardial
contrast enhancement by taking multiple sequential CTP images over
time as the contrast transits through the heart. The myocardial contrast
enhancement images can be analyzed visually or their enhancement over
time can be quantified in order to create time-attenuation curves (TAC).
These TAC's are proportional to myocardial blood flow and can be
evaluated in various ways as explained below. Advantages of dynamic
CTP include the ability to quantify myocardial blood flow (MBF), myo-
cardial blood volume, and potentially other hemodynamic parameters by
applying mathematic models to vascular contrast enhancement and the
tabulated myocardial TAC's (Table 3). The parameters used and how
accurately they can be determined depends strongly on the temporal
sampling rate. The disadvantages of dynamic CTP protocols are the ra-
diation exposure is higher than that of static CTP, cardiac and patient
motion, and lack of standardized models to quantify blood flow. To re-
duce radiation dose, automatic tube current modulation can be useful
with spiral dynamic perfusion CT57 and iterative reconstruction techni-
ques to maintain image quality with lower radiation exposure (58) can
be used. Myocardial misregistration from patient and cardiac motion
during the relatively long dynamic CTP image acquisition can be reduced
using motion correction algorithms.55
4.2.1. Dynamic CTP minimal scanner requirements
Dynamic perfusion imaging requires a system capable of acquiring
repeated moderate spatial resolution images that cover the entire
myocardium (which in adults is about 7–10cm) within the 20–30
second breath hold required for contrast transit. High temporal re-
solution is required to minimize motion artifacts related to a fast heart
rate during pharmacologic stress or patient breath hold. Sufficient
temporal sampling is required for TAC generation and quantification or
semi-quantification of myocardial perfusion. Second and third genera-
tion dual-source computed tomography (CT) systems and later
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Journal of Cardiovascular Computed Tomography 14 (2020) 87–100
Advantages Disadvantages
• Simple • May be more susceptible to artifact and
• Rapid analysis interpretation errors
• Simple adjunct • Dependent on good image quality
• Semiquantitative • Susceptible to artifact
• Unclear if added value over qualitative assessment
• Simple • May be susceptible to artifact and interpretation
• Rapid analysis errors
• Simple calculation • Semiquantitative
• Shorter imaging • Requires dynamic CT imaging
time • Questionable accuracy
• Imaging of peak attenuation critical
• Fully quantifiable • Longer scan and more susceptibility to artifacts
flow (ml/min/gram) • Requires dynamic CT imaging
• Higher • Errors within model are possible
quantification
accuracy
• Higher radiation than other CTP
generation single-source CT systems fulfill these requirements. The
number of longitudinal detector rows/data channels that can simulta-
neously measure x-ray attenuation determines the volumetric z-axis
coverage of the CT scanner. Both 64-detector CT and first-generation
dual-source CT have limited z-axis coverage per gantry rotation (∼4
cm), if the table remains in the same position.59 For these scanners, the
CT table and patient need to move back and forth through time (shuttle
mode) to cover the entire myocardium. In second- and third-generation
dual-source CT and z-axis coverage of 38–40 mm, ECG-triggered se-
quential-scanning with table movement back and forth between the two
scanning positions provides a final coverage of 7.3–8cm. This coverage
is limited but large enough to collect information about myocardial
perfusion in the end-systolic phase, when the size of the heart is smaller
and the thickness of the myocardial wall is higher (compared with
diastolic phase).54
Using higher slice systems with larger z-axis coverage (detector
width of 12–16 cm) provides whole heart coverage per gantry rotation.
However, the lower temporal resolution of these systems increases the
risk of motion artifacts with higher heart rates. This may be mitigated,
to some extent, by the use of multisector reconstruction.
4.2.2. Timing of the scan and frequency of temporal sampling
Dynamic perfusion relies on accurately measuring arrival, peak and
washout of the first pass of myocardial contrast and aorta or left ven-
tricle over time. CTP images should be acquired during the early por-
tion of first-pass circulation, when the iodinated contrast is mainly in-
travascular60 Images are then acquired repeatedly at different time
points yielding the various temporal frames of the dynamic dataset,
generally 1–3 seconds apart. Each frame of the dynamic dataset gen-
erates a point of the TAC in each voxel of the myocardium, as well as a
point of the arterial input function in the aorta. Other crucial time
points include at least one baseline (pre-contrast) frame including the
whole myocardium, and adequate frames to define the upslope, peak
and early portion of the downslope of the time-attenuation curves.
4.2.3. Dual-source CT
Dual source CT with detector coverage that cannot cover the entire
myocardium requires “shuttling” the patient back and forth to image
the myocardium over time. With the shuttle mode technique, CT data
A.R. Patel, et al.
are acquired at two alternate table positions by moving the table back
and forth covering the entire myocardium in the end-systolic phase.54
Each stack contains attenuation data of the blood pool in the des-
cending aorta or left ventricular cavity as well as attenuation data of the
myocardium. Second and third generation dual-source technology al-
lows CTP acquisition at every heart beat for up to 63 beats per minute,
and every second heart beat above 63 beats per minute, in keeping with
a temporal sampling of 2–3 s under pharmacological stress condi-
tions.54,61,62 These are generally sufficient to allow the estimation and
fit of the TAC while limiting radiation exposure to patients.
This allows construction of the arterial input function with double
temporal sampling compared to the myocardium, and provides suffi-
cient time points for the construction and fitting of the TAC's for both in
left ventricle or aorta (arterial input function) and in each voxel of the
myocardium (tissue). The scan typically acquires 10–15 whole myo-
cardial volumes corresponding to 10–15 time points (or frames) over
20–30s.
4.2.4. Single source CT
Single source CT with smaller (<8 cm) coverage also requires
“shuttling” the patient back and forth over time, similar to dual source
CT, but may not have the temporal resolution to obtain all needed data
points for TAC generations. Larger coverage scanners (>8 cm) image
the whole heart every rotation without table motion.63 This is achieved
with the 320-detector CT scanner that can provide up to 16 cm of
coverage along the z-axis. This allows image acquisition of the heart
within a fraction of a single heartbeat, with more homogeneous con-
trast attenuation of the myocardium and no reconstruction slab arti-
facts. Single source scanner generally require a minimum number of
scans (∼10–15) to generate robust TAC although more recent data are
challenging this requirement.64 Contemporary acquisition protocols
can also vary the sampling rate during the passage of contrast, to obtain
more data points during the important upslope portion of the TAC.
4.2.4.1. Image artifacts for static and dynamic CTP. Beam hardening is a
well-known artifact which occurs when x-ray beams pass through high-
density objects, in which lower energy beams are absorbed, leading to a
hypoenhanced region that may appear as a falsely-positive perfusion
defect. This commonly occurs in the basal inferolateral wall, which is
adjacent to the contrast-enhanced descending aorta. There are a
number of reconstruction algorithms that have been described in an
effort to correct for beam hardening, but it remains a problematic
artifact in CT-MPI imaging.65–67
The visual interpretation of perfusion defects in CT-MPI can be
limited by suboptimal image quality and relatively poor signal-to-noise
ratio due to patient body habitus and the desire to minimize radiation
exposure to the patient. Iterative reconstruction algorithms have been
developed in an effort to reduce image noise in CT. These algorithms
provide improved signal-to-noise and contrast-to-noise ratios without
requiring an increase in radiation. This new reconstruction strategy is
especially promising for CTP imaging, as it offers an effective way to
acquire additional images with only minimal radiation exposure,
without compromising image quality and diagnostic accuracy58,68
4.3. Dual energy CTP
Overview. Dual energy CT (DECT) imaging produces a spectrum of
photon strengths (kVp) during CT acquisition that, when measured with
modern CT scanners, are processed into different imaging spectra.
DECT has the ability to differentiate iodinated contrast from back-
ground tissue, water and fat by utilizing the reactions of each of these
substances to photons at the so called “k-edge”. DECT has the ad-
vantage of overcoming some challenges of interpreting CTP images
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Journal of Cardiovascular Computed Tomography 14 (2020) 87–100
such as beam hardening artifacts and the relatively low contrast to
noise ratio needed to keep radiation exposure judicious over several
heartbeats. DECT scanning techniques vary according to the type of
scanner whether it has one or two x-ray tube sources.
Dual Source DECT. In the dual source scanners, two tubes are placed
perpendicular in the same gantry with an angle offset of ∼90°. One of
the tubes operates at 140 kV and the other at 80–100 kV. A limitation of
this approach is that when both sources are active at the same time,
cross-scatter can result in artifacts and degraded contrast-to-noise ratio.
The best achievable temporal resolution in this configuration is 165
milliseconds; however, reconstruction algorithms have been described
that may further improve this.69 DECT perfusion studies with dual
source are acquired with retrospective ECG-gating and ECG-dependent
tube current modulation.
Single Source DECT. There are currently two approaches for dual
energy CT using only one x-ray tube source: the rapid kV switching
during rotation and the dual layer detector approach. With the first
approach, rapid KV switching occurs within a single tube between low
and high tube potentials every 0.5 milliseconds and are generally 80
and 140 keV. Each pair of 80 and 140 kV projections are basically
obtained from an identical view angle. DECT using this approach only
operates in a prospective ECG-triggered mode and a wider padding is
required for imaging both systolic and diastolic phases. With the second
approach, a dual layer detector system utilizes two different scintil-
lating materials fused together with a single source CT gantry. The
upper layer detects the lower energy photons and permits higher energy
X-ray photons to pass through it to be detected by the lower layer. The
two signals for the two detectors would resemble two x-rays in two
different energy ranges. Advantages of this design is that at each view
the high- and low-energy projections are exactly registered with respect
to each other. A potential disadvantage is less spectral separation be-
tween low and high energy projections that can lead to an inadequate
material decomposition and beam hardening correction.
4.3.1. Image reconstruction and analysis using DECT
DECT allows for two types of analyses, either monochromatic ex-
amination or material decomposition, to reduce beam hardening and
other artifacts. The monochromatic examination renders each image at
a monochromatic energy level over a wide spectrum of energies that
ranges between 40 keV and 140 keV. This means that for each image,
there are several possible energy levels for discrimination of chemical
composition by mapping the differing interactions with x-ray photons.
Those with high atomic number has inverse conspicuity, or HU density,
to photon energy with DECT. High atomic numbers result in higher
density (HU) at lower energy levels (for example, 40 keV) and lower
density (HU) at higher energy levels (140 keV). Iodinated contrast has a
high atomic number and thus has a higher density at low energy levels
and a relatively lower conspicuity at high energy level reconstructions.
While low energy levels depict higher contrast enhancement in the
myocardium, they are associated with increased noise, and are subject
to increased beam hardening artifacts that can mimic perfusion ab-
normalties and increase false positive readings unless dedicated algo-
rithms are used.70 Conversely, higher energy levels yield lower myo-
cardial and intravascular contrast but lower image noise, and decreased
beam hardening artifacts. Thus, DECT may reduce or even eliminate
beam hardening by generating monochromatic images. Once the op-
timal energy level is determined, grayscale, color mapped, or color-
overlaid images can be utilized for analysis. Semi-quantitative and
quantitative analysis can be complemented in a similar manner to
single energy CT as described below.
The second type of DECT evaluation is material decomposition
(MD).71 MD is based upon different attenuation coefficients of various
tissues, which in turn depend on the energy levels of the X-ray beam.
A.R. Patel, et al. Journal of Cardiovascular Computed Tomography 14 (2020) 87–100

Fig. 2. Potential display for static CTP images. A surface rendered image (bottom left) suggests the presence of a stenosis in the left anterior descending artery. Stress
CTP images are shown in the 2-chambr (top left), 3-chamber (top middle), and short axis (bottom middle) imaging planes and demonstrate the presence of an apical
anterior perfusion defect. The finding is verified on the quantitative bullseye plots (top and bottom right).

MD yields information about tissue atomic number and can provide
“mass density maps” for basic materials such as water or iodine. MD
allows the visual isolation of a material as well measurement of its
concentration in a given voxel (mg/Ugr/mm3).56,58,72 In myocardial
CTP, the amount of iodine can be measured in order to establish normal
or an abnormal perfusion. MD can be portrayed in grayscale or in color
scale.
5–10% intervals. Raw CTA and CTP data files should be retained until
image interpretation is complete. Images may be viewed in systolic
and/or diastolic phases, depending on acquisition parameters.
CTP images may be viewed in static and/or dynamic CTP modes,
depending on the acquisition. If available, qualitative and quantitative
ventricular function should be reported including regional wall motion
abnormalities to correlate with the CTP findings.

5. CTP image analysis Overview 5.1. Static CTP image analysis

We recommend interpretation of coronary CTA and myocardial CTP
images be performed concomitantly. Accordingly, workstations used for
CTP interpretation should possess all requirements for standard coronary
CTA interpretation. This constitutes the ability to facilitate two and
three-dimensional display of the coronary arteries and the myocardium
subtended in all conventional reconstruction formats. These include axial
and multiplanar reformations (MPR), maximum intensity projections
(MIP), minimal intensity projections (MinIP), and average projections.73
If dynamic CTP is performed, then software that allows visualization of
myocardial enhancement over time is also required.
CTP images should be viewed using the available cardiac phases to
reduce motion-related artifacts. Diagnostic accuracy may be improved
by the use of additional image reconstructions performed at a phase
with the least cardiac motion. For this reason, images may be re-
constructed from multiple phases of the cardiac cycle, typically at
In static visual CTP interpretation, myocardial images are typically
arranged using three standard orthogonal views - the short axis, vertical
long axis, and horizontal long axis (Fig. 2).74 CTP images usually use a
narrow window width of 200–300 and level setting of 100–150 with an
average slice thickness of 5–8 mm. Images may be viewed in minimal
intensity projection (MinIP) or average intensity projections, although
the former may be more sensitive. CTP images should be automatically
or visually divided into standard American Heart Association 17 myo-
cardial segment model.75 Dedicated perfusion software platforms
should also allow side by side display and comparison of rest and stress
images to examine the presence and extent of reversibility of perfusion
defects. The ability to review the perfusion images acquired during
different cardiac phases in order to determine if a potential perfusion
defect persists during multiple phases of the cardiac cycle can help
improve diagnostic confidence. In the event a true perfusion defect has

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been identified, visual coronary CTA analysis or automated software
should enable the interpreter to track the stenosis in the major epi-
cardial coronary artery or branch that subtends the myocardial segment
with the corresponding perfusion defect.
5.1.1. Semi-quantitative analysis for static CTP
Qualitatively, perfusion defects are visually evaluated using the
American Heart Association 17-segment model. We recommend that
perfusion defects be “scored” using the following:
1) Severity. Hypoperfusion severity should be scored by whether hy-
poperfusion is present (binary). In addition, it may be useful to
describe the severity of the defect using a continuous scale of mild,
moderate, or severe.
2) Size. The size of the perfusion defect (small, medium, or large)
should be described, as well as whether it is transmural (>50%) or
non-transmural (<50%).
3) Reversibility. Perfusion defects should also be described as re-
versible (perfusion defect present only on the stress CTP images),
fixed (perfusion defect present and similar on both rest and stress
CTP images), or partially reversible (perfusion defect present on
both the stress and rest CTP images but less pronounced of the rest
images).
CTP software is also available which permits evaluation of other
semi-quantitative metrics such as the transmural perfusion ratio (TPR),
absolute contrast map and various other types of perfusion indexes. TPR
is the ratio of the subendocardial attenuation of a specific segment of
myocardium and the entire epicardial attenuation. This index has been
validated using quantitative coronary angiography14 and fractional
flow reserve,76 and can be used to guide visual reads. This can be dis-
played as an average for the entire myocardial segment or within each
pixel of the segment using a 17-myocardial segment polar plot which
effectively presents a 34 segment model.14 Another proposed CTP index
normalizes myocardial subendocardial perfusion to the LV cavity HU
density resulting in a segmental myocardial perfusion index.77 This
allows for different “normal” CTP attenuation in certain segments that
are prone to more attenuation due to adjacent structures, such as the
basal inferior wall. A related semi-quantitative CTP method measures
the 3-dimensional myocardial attenuation in volumetric myocardial
segments, which is normalized to the LV cavity but also compared to a
histogram of a reference normal myocardial segment from a library of
normal individuals. The hypoenhanced voxels in a myocardial segment
reflects the relative volume of perfusion defect, and the defect severity
is estimated by the difference in the positions of peaks of the attenua-
tion histogram of the particular segment of interest and the reference
segment. Together, these indices are used to estimate an overall defect
volume and severity. This normalized voxel assessment has been shown
to have good agreement with SPECT MPI for rest CT-MPI, with im-
proved detection for CAD noted with the addition of stress CT-MPI.45,78
Despite the number of available methods for semi-quantitative assess-
ment of myocardial perfusion for static CTP, there is no clear benefit of
using one method over another and the authors can make no re-
commendations for preferential use of any technique at present.
5.2. Semi-quantitative analysis for dynamic CTP
The result of the dynamic perfusion acquisition is a sequence of
volumetric CT scans, each consisting of overlapping axial slices usually
with a thickness of 1.5–3mm. The individual CT images are char-
acterized by a low contrast-to-noise ratio. Although more difficult to
interpret than static perfusion scans, enhancement heterogeneity may
readily be observed on the source images. From the time-resolved data
and temporal changes in CT attenuation it is possible to investigate a
94
Journal of Cardiovascular Computed Tomography 14 (2020) 87–100
range of myocardial perfusion parameters.79 The measured CT at-
tenuation values show a linear relation with the iodine concentration.
Sampling the myocardium or myocardial region of interest and then
charting the myocardial attenuation values over time create time-at-
tenuation curves (TAC's). The time-attenuation curves provide a semi-
quantitative measure of myocardial perfusion by normalizing against
slope or peak of the attenuation curve measured in the left ventricle or
aorta59 which is related to the arterial blood flow supplying the myo-
cardium and can be compared between different myocardial regions.
Ischemic myocardium will demonstrate a shallower upslope and lower
peak compared to normal myocardium.
5.2.1. Post-processing for quantitative analysis for dynamic CTP
Depending on the CT scanner and myocardial perfusion package
used, a number of pre-processing steps may be required. Correction of
myocardial displacement between phases is essential to measure
changes in attenuation. Phases with non-correctable displacement,
perhaps due to arrhythmia, may be entirely deleted from the analysis.
To measure the change in myocardial attenuation, it is important to
acquire one or more non-enhanced datasets, that serve as the baseline,
non-enhanced image for the TAC. To quantify the myocardial blood
flow, both a measure of the arterial input function and myocardial flow
are needed to model blood flow calculations in absolute blood flow
units (ml/min/gram of myocardial tissue). The arterial input function
can be approximated by placing a region of interest in the descending
thoracic aorta or left ventricular cavity and sampling the attenuation
over time. For shuttle-mode acquisitions, it is important to place a re-
gion of interest both in the upper and lower part of the scan to increase
the sampling rate. The software application may require further pre-
paration steps, such as isolation of the myocardial volume, or adjust-
ment of the image filtering to avoid excessive image noise. Semi-au-
tomated software applications exist to perform these functions, but
require visual conformation and possibly manual adjustments by ex-
perienced users to optimize quantitative measures.
5.2.2. Quantitative analysis for dynamic CTP
Calculation of absolute parameters of myocardial perfusion requires
more complex iodinated contrast kinetic modeling. Generally, two-
compartment models are applied that consider the blood flow into the
myocardium, the myocardial blood flow itself, and the extra-vascular
extraction rate of the contrast into the interstitial space. The most in-
vestigated method is the deconvolution model.59,80 By this approach,
the arterial input function, the tissue TACs, and the assumed temporal
exchange of contrast between the vessel and the interstitial space over
time (assuming a short contrast bolus) are deconvoluted with a CTP
model to derive quantitative flow.55,59,81 Preferably the sampling in-
terval should be less than the shortest transit time, although the number
of CTP images is limited by the scanner configuration and radiation
dose. The duration of scanning is further limited by the time of the
breath hold.
Other processing techniques have been reported although none
have not been widely validated. Patlak plot analysis was reported as an
approach to calculate myocardial blood flow.82 To overcome the lim-
ited number of images over time and specifically designed for the
shuttle-mode perfusion imaging technique, is a hybrid model com-
bining a simplified deconvolution algorithm with the maximum-slope
method.54 Using this method, myocardial blood flow can be calculated
by dividing the maximum slope of the fit model curve by the peak of the
arterial input function.61,62,82 In addition to myocardial blood flow,
myocardial blood volume may also be calculated. While other in-
dependent or derived hemodynamic parameters may be calculated,
which have established value in non-myocardial dynamic contrast en-
hanced imaging applications, these parameters have not been ex-
tensively investigated for myocardial perfusion imaging. The most
A.R. Patel, et al. Journal of Cardiovascular Computed Tomography 14 (2020) 87–100

Table 4
Summary of available studies validating static CTP.
Scanner type Imaging protocol Reference standard Na Radiation Dose (mSv)b Sensitivity (%) Specificity (%)

16
Kurata et al. 16 detector rows Retrospective SPECT-MPI 12 Not reported 90 79
George et al.14 64 &256 detector rows Retrospective QCA/SPECT-MPI 27 16.8 (64 CT) 81 85
21.6 (256 CT)c
Blankstein et al.4 64 DSCT Retrospective QCA/SPECT-MPI 33 9.1 93 74
Rocha-Filho et al.83 64 DSCT Retrospective QCA 34 9.8 91 91
Okada et al.84 64 DSCT Retrospective SPECT-MPI 47 10.0 Pearson r = 0.56 (rest) and 0.66 (stress)
Cury et al.85 64 detector rows Retrospective low resolution QCA 26 3.4 88 79
Ko S. et al.86 64 DSCT Retrospective MRI-MPI 41 8.6 91 72
Tamarapoo et al.17 64 DSCT Retrospective SPECT-MPI 30 15.7 92 86
Weininger et al.87 128 DSCT Retrospective (DECT) MRI-MPI 20 15.2 (DECT) DECT 93 DECT 99
Feuchtner et al.19 128 DSCT Prospective High pitch Spiral MRI-MPI 30 0.9 96 95
mode
Ko B. et al.76 320 detector rows Prospective FFR 42 5.3 76 84
George et al.18 320 detector rows Prospective CCTCA/SPECT- 50 7.0 100 85
MPI
Ko B. et al.88 320 detector rows Prospective FFR 40 4.5 95 95
Nasis et al.89 320 detector rows Prospective SPECT MPI 20 9.2 94 98
Bettencourt et al.20 64 detector rows Retrospective FFR 101 5.0 (including rest 71 90
CCTCA)
Rief et al.37 320 detector rows Prospective QCA 91 7.9 56 78
Pontone et al.25 320 detector rows Prospective FFR 130 2.5 ± 1.1 91 86
Rochitte et al.90 320 detector rows Prospective ICA/SPECT 381 9.3 80£ 74d
Cury et al.91 Multivendor Prospective SPECT 110 N/A 90μ 84e

a
Number of patients in the study who underwent both CTP and reference standard imaging modality.
b
Radiation dose only for the stress perfusion acquisition.
c
Only the radiation dose for both stress and rest perfusion was reported.
d
Assuming a summed stress score of 4.
e
Per patient results available only.

commonly used approaches for assessing myocardial perfusion using
static and dynamic CTP are summarized in Table 3.
5.2.3. Image display for dynamic CTP
For qualitative assessment, the dynamic perfusion images may be
displayed in the same orthogonal cardiac imaging planes as static CTP
with similar settings. Dynamic CTP images should be viewed during
contrast enhancement as a cine loop to qualitatively view of myocardial
contrast uptake over time. This also allows for visual confirmation of
significant patient or cardiac motion that may affect myocardial co-
registration over time. The results may also be displayed using color-
coded maps, where the shading represent particular myocardial per-
fusion values, such as myocardial blood flow or volume. The voxel-
based functional imaging maps may be sampled for (averaged) regional
perfusion values. While quantification of myocardial perfusion values
should be used to differentiate normal, ischemic, and infarcted myo-
cardium, there is no accepted positivity criterion with threshold values
that may be applied for interpretation. Thus, currently, relative differ-
ences in perfusion values between different myocardial segments has
been adopted in clinical practice.
6.2. Dynamic CTP clinical studies
Current evidence on the feasibility of dynamic myocardial CT per-
fusion imaging using contemporary CT scanners is summarized in
Table 5. Overall, studies were proof-of-concept studies demonstrating a
promising performance by dynamic perfusion CT for the detection of
functionally relevant CAD, with incremental diagnostic value over CT
angiography alone. The reference standard varied significantly among
the studies and included SPECT, MRI, PET, invasive angiography, and
invasive measurement of FFR with different FFR thresholds (0.75 vs.
0.80) for hemodynamically significant lesions. Also, derived myocardial
perfusion parameters (i.e. myocardial blood flow and volume) were not
employed in a standardized fashion to serve as a positivity criterion.
The reported associated radiation exposure varied but ranged from 5.3
to 13.1 mSv. Reported technical limitations included limited coverage
of the perfusion volume and cardiac and patient motion during long
breath holds of up to 30 seconds.
6.3. Dual energy clinical studies
Current evidence on the feasibility (efficacy) of dual energy myo-
cardial CT perfusion imaging is summarized in Table 6.

6. CTP clinical studies 7. CTP interpretation and reporting

6.1. Static CTP clinical studies
Current evidence on the feasibility (efficacy) of static myocardial CT
perfusion imaging using contemporary CT scanners is summarized in
Table 4. Overall, studies range from proof-of-concept studies to multi-
center studies demonstrating a promising performance by static perfu-
sion CT for the detection of functionally relevant CAD, with incremental
diagnostic value over CT angiography alone. The reference standard
varied significantly among the studies and included SPECT, MRI, PET,
invasive angiography, and invasive measurement of FFR for hemody-
namically significant lesions.
The components of a CTP structured report should include in-
formation regarding the following:
7.1. Clinical history and indications
This section should include the main clinical indication for the study
and specific signs and symptoms to support the clinical indication.
7.2. Technique or procedure description
This section should include pertinent information of image

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Table 5
Summary of available studies on the diagnostic accuracy of dynamic myocardial CT perfusion imaging. CAD: coronary artery disease; cMRI: cardiac magnetic
resonance imaging; FFR: invasive measurement of fractional flow reserve; PET: positron emission tomography; DSCT: dual-source computed tomography.
Author name Scanner type Imaging protocol Reference standard N Radiation Dose [mSv] Sensitivity (%) Specificity (%)

Bastarrika et al.92 128 DSCT Shuttle cMRI 10 1290.4 ± 233.3 mGy cm 86.1 98.2
Ho et al.93 128 DSCT Shuttle SPECT 35 9.15 ± 1.32 mSv (stress) 83 78
9.09 ± 1.4 mSv (rest)
Weininger et al.87 128 DSCT Shuttle SPECT 20 12.8 ± 2.4 mSv 86 98
Kono et al.94 128 DSCT Shuttle FFR 42 9.4 mSv 97.8 69.6
Bamberg et al.95 128 DSCT Shuttle FFR 33 10 ± 2 93 87
Kurata et al.96 256 detector rows Stationary Invasive Angiography 11 10.4 100 78.6
Bamberg et al.97 128 DSCT Shuttle cMRI 38 11.08 ± 2.0 100 75
Wang et al.98 128 DSCT Shuffle SPECT 30 12.8 ± 1.6 90 81.4
Kim et al.57 128 DSCT Shuttle cMRI 33 5.3 ± 1.0 82 84
Ebersberger et al.99 128 DSCT Shuttle SPECT 37 9.6 ± 4 86 96
Greif et al.100 128 DSCT Shuttle FFR 65 9.7 ± 2.2 95.1 74.7
Kikuchi et al.21 320 Single Temporal Volume O–H2O-PET 32 12.8 ± 2.9 85.7 92.3
Rossi et al.101 128 DSCT Shuttle FFR 80 9.4 84 81
Huber et al.63 256 detector rows Stationary FFR 32 9.5 75.9 100
Pontone et al.23 256 detector rows Stationary FFR 85 5.3 ± 0.7 mSv 73% 86%

Table 6
Summary of CT Perfusion studies validating dual energy CTP.
Author Scanner Type Imaging Protocol Reference Standard N Average CT Dose (mSv) Sensitivity (%) Specificity (%)

102
Ruzsics 2009 DSCT Shuttle, Rest SPECT 36 14 97 67
Bauer 201052 DSCT Shuttle, Rest CMR 36 9.7 77 97
Nagao 2010103 DSCT Shuttle, Stress SPECT, ICA 10 NR 86 75
Nance 201169 DSCT Shuttle, Rest ICA 12 NR 91 95
Ko 201186 DSCT Shuttle, Stress CMR 41 8.6 89 78
Wang 2011104 DSCT Shuttle, Rest SPECT 31 10.5 81 92
Meyer 2012105 DSCT Shuttle, Rest/Stress/Deleayed CMR 50 13.4 90 71
Ko 2012106 DSCT Shuttle, Rest/Stress ICA 45 16.5 89 74
Weininger 2012107 DSCT Shuttle, Stress SPECT 20 12.8 94 98
CMR 93 99
Delgado 2013108 DSCT Shuttle, Stress CMR 56 8.2 76 99
Ko 2014109 DSCT Shuttle, Rest/Stress CMR, ICA 40 4.2 42 83
4.6 87 79
Ko 2014110 DSCT Shuttle, Stress CMR 100 4.2 97 36
Kim 2014111 DSCT Shuttle, Stress/Rest CMR 50 11.4 94 71
Zhao 2014112 DSCT Shuttle, Rest ICA 60 NR 94 91
Kido 2014113 DSCT Shuttle, Stress ICA 21 7.7 67 92
De Cecco 2014114 DSCT Shuttle, Rest/Stress ICA 29 5.8 95 50
SPECT 6.6 91 38
Delgado 2016115 DSCT Shuttle, Stress CMR 36 5.4 100 90

acquisition and image reconstruction of coronary CTA and myocardial
CT perfusion. Several aspects of image acquisition should be included,
such as:
• type of studies (including calcium score, CCTA, rest and stress
myocardial CT perfusion, delayed enhancement CT)
• equipment (scanner type – 64-slice, 128-slice, 256-slice, 320-slice or
dual-source),
• technical acquisition protocol (with reference to both stress and
rest/CTA acquisition as well as acquisition modes: prospective vs
retrospective, static vs dynamic perfusion),
• type and amount of contrast (for both stress and rest/CTA acquisi-
tions),
• medications use (including stress vasodilator agent and sequence of
testing, such as rest then stress CTP),
• clinical parameters during the procedure, including heart rate and
any complications or side effects (particularly symptoms or side
effects during the administration of stress vasodilator agent).
• Image Reconstruction should include all the performed reconstruc-
tion modes and descriptions for any semi-quantitative or quantita-
tive methods used.
7.3. Findings
The study quality needs to be described for each component of the
examination and the presence of any significant artifacts that may affect
image quality and study interpretation. The artifacts specific to cor-
onary CTA and myocardial CTP should be included in the report, such
as beam hardening artifacts, motion artifacts, misalignment, etc.
Perfusion defects should be assessed qualitatively by comparing the
rest and stress acquisitions based on the severity (mild, moderate and
severe), extent (small, medium and large) and reversibility (reversible,
partially reversible and fixed) as described above. Quantitative or semi-
quantiative information can be included, if such techniques were uti-
lized. When available, global and regional ventricular function assess-
ment should be included, particularly in association with any myo-
cardial perfusion abnormality.
Coronary CTA findings should be described separately in a per-
vessel and per segment distribution for stenosis and plaque assessment
following the updated SCCT guidelines for interpretation and re-
porting.73 This includes a complete report of the non-coronary cardiac
structures.

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Table 7
Key consensus statements for CTP.
1. We recommend that myocardial CTP may be added to coronary CTA when there is a high likelihood of ischemic heart disease, known CAD, prior coronary intervention, or
significant calcifications, Additionally, CTP may be added when there is a known stenosis of indeterminate functional significance. In such cases, myocardial CTP is
recommended if knowledge regarding the presence and severity of ischemia would impact patient management and CTP is feasible.
2. Myocardial CTP imaging with pharmacologic stress testing requires supervision by a trained medical provider who is experienced in the administration of pharmacologic
stress agents and stress testing.
3. Continuous 12-lead ECG monitoring may be performed using radiolucent electrodes and leads. Alternatively, 12-lead ECG monitoring can be interrupted during scan
acquisition while continuous rhythm is still being recorded and monitored by the scanner console. Upon the completion of imaging, a 12 lead ECG should be performed to
ensure there are no significant changes from baseline suggestive of post-stress myocardial ischemia or injury.
4. If an automated bolus-tracking algorithm is utilized, a region of interest should be defined in either the proximal-ascending or mid-descending thoracic aorta. The
automated trigger should be set to a Hounsfield Unit (HU) threshold that is ∼80-100HU above the baseline HU of the selected reference area immediately prior to the
contrast injection. After the scanner is triggered, a short pause (∼5 seconds) is required to allow for breath-hold instructions to be given. Contrast dose and flow rate is
typically ∼60–70ml injected at 5–6ml/sec.
5. The optimal sequence of scans (rest first versus stress first) has not been determined and either sequence has advantages and disadvantages. Our committee suggests
assessment of factors that could impair exclusion of obstructive CAD on coronary CTA (e.g. significant coronary calcium, prior coronary event or coronary revascularization,
high pre-test probability of obstructive CAD) prior to decision to perform CTP. Those patients with a high likelihood or known significant coronary disease or severe amount
of CAC may undergo stress myocardial perfusion imaging first; whereas, patients who lack the above features may undergo coronary CTA first.
6. A delay of 10–20 minutes between the rest and stress CT acquisitions is recommended to minimize myocardial contrast agent contamination and to eliminate the potential
adverse interaction of pharmacologic stress agents and nitroglycerin administration.
7. There is no consensus about whether imaging should be performed at end-systole or during diastasis although most larger trials to date have selected diastole. A multiphase
acquisition which includes phases from both systole and diastole can be considered so that the phase with the least amount of artifact can be selected for analysis
retrospectively.
8. For optimal image interpretation, images may be reconstructed from multiple phases of the cardiac cycle, typically at 5–10% intervals of the R-R image acquisition window
and raw CTA and CTP data files should be retained until image interpretation is complete.
9. In static visual CTP interpretation, myocardial images are typically arranged using three standard orthogonal views - the short axis, vertical long axis, and horizontal long
axis. CTP images usually use a narrow window width of ∼200–300 and level setting of ∼100–150 with an average slice thickness of 5–8 mm. Images may be viewed in
minimal intensity projection (MinIP) or average intensity projections
11. Perfusion defects should be described in terms of size, transmurality, and reversibility in the context of the degree of stenosis in the supplying coronary artery.

7.4. Impression or conclusion
It is recommended to start the impression with an overall statement
summarizing the findings: For example, “severe coronary athero-
sclerosis with significant 3-vessel anatomic disease and a medium size
area of reversible ischemia in the LAD territory only”. It is important to
relate any perfusion deficits to the culprit vessel since this may have
treatment implications.
Subsequently, all other available information should be reported,
such as: 1) total calcium score, 2) presence or absence of significant
coronary stenosis, 3) presence or absence of myocardial perfusion de-
fects, 4) information related to global and regional LV function, 5) Any
other relevant cardiac or extra-cardiac findings.
7.5. Images
Attaching representative images of important pathology for myo-
cardial CT Perfusion and CCTA imported from the workstation is sug-
gested. For referring physicians, short-axis images of myocardial CT
perfusion are often preferable.
8. Summary and final conclusions
Myocardial CTP provides incremental value over coronary CTA.
This document provides some consensus regarding the heterogeneity
that currently exists about the use of pharmacologic stress agents,
imaging sequences, scanner types, acquisition protocols, post-proces-
sing, and interpretation of CTP results. This document represents the
consensus opinion of international experts in myocardial CTP imaging
and is meant to serve as a resource for clinical implementation, resource
allocation, and future investigations related to CTP. Key statements
selected by the committee are shown in Table 7.
Conflict of Interest
Grants and Research for the authors:
Amit Patel: General Electric; Philips; Astellas, Speaker's Bureau:
Astellas - stress testing; Alnylam - amyloidosis.
Ron Blankstein: Astellas Inc; Amgen, Inc., Consultant: Amgen Inc.
Fabian Bamberg: Bayer; Siemens Healthineers, Speakers Bureau: GE;
Siemens Healthineers; Bracco.
Kelley Branch: Bayer; Kestra; Astellas; Eli Lilly, Consultant: Bayer;
Janssen; Astra Zeneca.
Ricardo Cury: GE Healthcare, Consultant: Covera Health, Stocks:
Cleerly, Royalties: IBM Watson - RASF Innovations.
Brian Ghoshhajra: Siemens Healthcare, Stocks: Apple, Inc.
Brian Ko: Canon Medical, Speakers Bureau: Medtronic; St. Jude Medical.
Koen Nieman: Siemens Healthineers; GE; Bayer; HeartFlow.
Francesca Pugliese: Siemens Healthineers.
Joseph Schoepf: Astellas; Bayer; GE; Siemens, Consultant: Guerbet,
Speaker's Bureau: HeartFlow.
Richard George: AstraZeneca, Patents: AstraZeneca, Employee:
AstraZeneca.
Gianluca Pontone: GE Healthcare; Bracco; HeartFlow, Speakers
Bureau: GE Healthcare; Bracco; Bayer; Medtronic; HeartFlow.
Gianluca Pontone: GE Healthcare; Bracco; HeartFlow, Speakers
Bureau: GE Healthcare; Bracco; Bayer; Medtronic; HeartFlow.
Acknowledgment
Richard T. George.
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