Exercise Stress CMR

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 Primary Role of Stress Tests

** Need to reproduce
this if using for
illustration

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 Assessment of Coronary Artery Disease
Exercise stress
APPROACH Vasodilators
Dobutamine

PRINCIPLE Induce hyperemia Induce ischemia

MANIFESTATIONS Perfusion Defects Regional wall motion ECG Changes

abnormalities

IMAGING SPECT/PET CMR ECHO TMX

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 Advantages of Exercise Stress

• Physiological stress to induce ischemia

• Exercise parameters have incremental

prognostic value (BP/HR during exercise
and recovery, METS, Duke’s score)

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 Exercise CMR – Dream or Reality?

• Potential challenges:
1. Breath holding image during exercise is
challenging
2. Free breathing imaging lack adequate
spatiotemporal resolution

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 ** Images taken off the net

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 Exercise Treadmill CMR: EXACT TRIAL

Multi-center
Known or suspected CAD, n=96

Diagnostic accuracy for CAD >70%

Sensitivity = 79%
Specificity = 99%
NPV = 96%
PPV = 92%

Raman et al. JAHA 2016;5:e003811

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 Exercise Treadmill CMR

Advantages Disadvantages
Physiologic stress modality Peak Exercise Imaging
Ability to monitor ECG during exercise Time delay in transferring patients
Excellent diagnostic accuracy
Prognostic value (short term)*

*J Cardiovasc Magn Reson. 2010;12:1-9

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 Exercise Bike CMR

• Image acquisition at
every stage

• Minimize delay in
transferring patients

• Free breathing imaging

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 Exercise Bike CMR
NHCS Experience – 1.5T Siemens Aera

Breath-held ECG Triggered Free Breathing ECG Triggered

Spatial Resolution: 1.6x1.3x8.0mm Spatial Resolution: 3.3x2.3x8.0mm

Temporal Resolution: 30 phases/cardiac cycle Temporal Resolution: 39ms

Le, Chin. JCMR 2017;19(1):7

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 Case 1

• 24 year old male

• Referred for suspected dilated
cardiomyopathy
• No significant family history of
cardiomyopathy and sudden cardiac death
• Exercises about 3 hours a week – gym
and basketball

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 LVMi: 69g/m2 (<65g/m2)
LVEDVi: 115ml/m2 (<103ml/m2)
LVESVi: 62ml/m2 (<45ml/m2)
LVSVi: 54ml/m2 (40-63ml/m2)
LVEF: 47%

Normal RV size and function

Normal atrial sizes
No fibrosis, infarction and infiltration

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 Case 2

• 20 year old male

• Claims very fit (football, exercises
regularly)
• No past medical history
• Family history not significant

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 LVMi: 44g/m2 (<65g/m2)
LVEDVi: 106ml/m2 (<103ml/m2)
LVESVi: 64ml/m2 (<45ml/m2)
LVSVi: 43ml/m2 (40-63ml/m2)
LVEF: 40%

Normal RV size and function

Normal atrial sizes
No fibrosis, infarction and infiltration

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 Who has an abnormal scan?

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 Exercise Stress CMR
CASE 1 (Peak: 175w) CASE 2 (Peak: 125w)

Baseline CI: 3.5L/min/m2 Baseline CI: 3.3L/min/m2

Peak CI: 11.2L/min/m2 Peak CI: 8.3L/min/m2
(91%tile for age and sex) (17%tile for age and sex)

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 Case 3

• 57 year old male

• Smoker (2 packs per day), hyperlipidemia,
hypertension and diabetes

• Referred for chest pain with exertion

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 Regional Wall Motion Abnormalities

At Rest Peak Exercise (50w)

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 Perfusion Defects

Peak Exercise
(50w)

At Rest

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 Myocardial Infarction LGE

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 Impaired exercise response
Baseline CMR Measurements
LVMi: 67g/m2 (<65g/m2)
LVEDVi: 107ml/m2 (<103ml/m2)
LVESVi: 47ml/m2 (<45ml/m2)
LVSVi: 61ml/m2 (40-63ml/m2)
Regional wall motion Perfusion Defects
LVEF: 56% abnormalities

Exercise CMR Measurements

Baseline CI: 4.0L/min/m2
Peak exercise CI: 6.6L/min/m2
(6%tile for age and sex)

Myocardial Infarction

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 Coronary Angiogram

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 Final Thoughts …

• Exercise stress CMR is evolving and has

a huge potential as a stress modality to
assess regional wall motion AND
perfusion defects

• More studies needed to validate the

diagnostic and prognostic value in
various cardiac conditions

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