Cardiopulmonary Imaging Original Research

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1 Cardiopulmonary Imaging Original Research De Cecco et al. Cardiopulmonary Imaging Original Research Carlo Nicola De Cecco 1,2 Brett S. Harris 1 U. Joseph Schoepf 1,3 Justin R. Silverman 1 Cullen B. McWhite 4 Aleksander W. Krazinski 1 Richard R. Bayer 3 Felix G. Meinel 1,5 De Cecco CN, Harris BS, Schoepf UJ, et al. Keywords: coronary CT angiography, dual-energy CT, high-risk population, myocardial perfusion imaging, SPECT DOI: /AJR Received August 13, 2013; accepted after revision October 17, This study was supported by a research grant provided by Bracco Diagnostics. U. J. Schoepf is a consultant for or receives research support from Bayer, Bracco, GE Healthcare, and Siemens Healthcare. 1 Department of Radiology and Radiological Science, Medical University of South Carolina, Ashley River Tower, MSC 226, 25 Courtenay Dr, Charleston, SC Address correspondence to U. J. Schoepf (schoepf@musc.edu). 2 Departments of Radiological Sciences, Oncology, and Pathology, University of Rome Sapienza Polo Pontino, Latina, Italy. 3 Division of Cardiology, Department of Medicine, Medical University of South Carolina, Charleston, SC. 4 South Carolina Clinical and Translational Research Institute, Medical University of South Carolina, Charleston, SC. 5 Institute for Clinical Radiology, Ludwig-Maximilians- University Hospital, Munich, Germany. WEB This is a web exclusive article. AJR 2014; 203:W70 W X/14/2031 W70 American Roentgen Ray Society Incremental Value of Pharmacological Stress Cardiac Dual-Energy CT Over Coronary CT Angiography Alone for the Assessment of Coronary Artery Disease in a High-Risk Population OBJECTIVE. The purpose of this article is to prospectively determine the value of stress dual-energy CT (DECT) myocardial perfusion imaging to coronary CT angiography (CTA) for the assessment of coronary artery disease (CAD) in a high-risk population. SUBJECTS AND METHODS. We prospectively enrolled 29 consecutive patients who were referred for cardiac SPECT examinations for known or suspected CAD to also undergo pharmacologic stress cardiac DECT. In 25 patients, cardiac catheterization was available as the reference standard for morphologically significant stenosis. The performance of coronary CTA alone, DECT myocardial perfusion alone, and the combination of both was assessed by calculating sensitivity, specificity, and AUC values. RESULTS. For morphologically significant stenosis, coronary CTA alone and myocardial DECT assessment alone had 95% sensitivity and 50% specificity. The combined approach yielded 100% sensitivity and 33% specificity if either was positive and 90% sensitivity and 67% specificity if both were positive. The AUC value was highest (0.78) if both were positive. For hemodynamically significant lesions, coronary CTA alone had 91% sensitivity and 38% specificity, and DECT alone had 95% sensitivity and 75% specificity. The combined approach yielded 100% sensitivity and 38% specificity if either was positive and 86% sensitivity and 75% specificity if both were positive. AUC values were highest for DECT alone (0.85) and the both positive evaluation (0.80). CONCLUSION. The combined analysis of coronary CTA and DECT myocardial perfusion reduces the number of false-positives in a high-risk population for CAD and outperforms the purely anatomic test of coronary CTA alone for the detection of morphologically and hemodynamically significant CAD. C oronary CT angiography (CTA) is the primary noninvasive imaging technique for morphologic assessment of the coronary arteries and has gained widespread clinical acceptance, particularly in patients with a lowto-intermediate risk of coronary artery disease (CAD), because of its excellent negative predictive value [1]. CT can also be used to simultaneously assess the status of the myocardial blood supply, thus offering a comprehensive evaluation of coronary heart disease [2]. One of the described avenues for assessment of the myocardial blood supply consists in dual-energy CT (DECT) acquisitions during first-pass arterial enhancement. Although this approach does not truly represent perfusion, but rather a snapshot of the myocardial iodine distribution during imaging, for simplicity this method shall be referred to as perfusion imaging for the purpose of this contribution. Myocardial perfusion DECT can be performed using dual-source CT [3] or single-source CT with rapid kilovoltage switching [4]. It has been found that DECT has advantages over single-energy CT for performing first-pass myocardial perfusion imaging [5]. Specifically, DECT reduces beam-hardening artifacts and directly visualizes myocardial iodine content. Thus, perfusion defects and late enhancement are often more easily recognized on DECT [6]. A limited number of studies have compared DECT myocardial perfusion imaging to SPECT or cardiac MRI [3, 6 10]. These studies have found good accuracy of DECT for myocardial perfusion defects. The performance of coronary CTA is affected by the pretest risk of CAD. In particular, the specificity of coronary CTA can be limited by extensive coronary calcification, which can cause artifacts that may lead to false-positive findings. Accordingly, cur- W70 AJR:203, July 2014

2 rent guidelines consider coronary CTA inappropriate in high-risk populations [11]. With such patients, the combined approach of coronary CTA and myocardial CT perfusion assessment could be useful to reduce the number of patients who are needlessly referred to catheter angiography because of false-positive coronary CTA findings. Therefore, the purpose of this prospective investigation was to determine the value of adding adenosine stress DECT myocardial perfusion imaging to coronary CTA for CAD assessment in a high-risk population using SPECT and catheter angiography as the reference standards. Subjects and Methods Study Population This study was institutional review board approved and HIPAA compliant. Written informed consent was obtained from all patients after a thorough explanation of the study purpose and the involved risks. We prospectively enrolled 30 consecutive patients who were clinically referred for cardiac SPECT examination for known or suspected CAD. Patients were considered not eligible for the study if they were a pregnant or nursing woman, had received cardiac-related surgical intervention within the 30 days before the SPECT examination, were unwilling to comply with the protocol requirements, or suffered from any of the following: active wheezing, asthma, second or third degree heart blocks (without functioning pacemaker), acute psychiatric disorder, substance abuse, claustrophobia, impaired renal function (creatinine level, > 1.5 mg/dl), or any unstable condition. Of the 30 patients who were enrolled, one was excluded from the study population because of extensive motion artifacts that occurred during the image acquisition. Thus, the final population consisted of 29 patients (23 men and six women) with an average (± SD) age of 60 ± 11 years and an average body mass index (kg/m 2 ) of 32 ± 11 (Table 1). The prevalence of cardiac risk factors was very high (Table 1). Twenty-six patients (90%) had a history of angina, and 16 patients (55%) had experienced myocardial infarction before the examination. A significant portion of patients had been previously treated with percutaneous coronary intervention (n = 15; 52%) or coronary artery bypass grafting (n = 6; 21%) or both. The average heart rate at baseline was 68 ± 15 beats/min. Twenty-five of 29 patients (86%) had a cardiac catheterization performed within 1 month of the CT examination, which were available for comparison. TABLE 1: Patient Demographic Characteristics Characteristic Value No. of patients 29 Age (y), mean ± SD 60 ± 11 Female sex 6 (21) Body mass index (kg/m 2 ), mean ± SD Baseline heart rate (beats/min), mean ± SD Cardiovascular risk factors 32 ± ± 15 Diabetes 9 (31) Smoking 12 (41) Dyslipidemia 25 (86) Hypertension 25 (86) Family history of coronary artery disease Medical history 18 (62) Angina 26 (90) Myocardial infarction 16 (55) Percutaneous coronary intervention 15 (52) Coronary artery bypass grafting 6 (21) Note Except where noted otherwise, data are number (%) of patients. CT Image Acquisition All patients were examined on a second-generation dual-source CT system (Definition Flash, Siemens Healthcare) in DECT mode. DECT studies were acquired during peak pharmacologic stress, at rest, and 6 minutes after the last contrast agent injection with retrospective ECG-gating, ECG-dependent tube current modulation, and the following scan parameters: mm (stress, delayed) or 0.6-mm (rest) detector collimation with z-flying focal spot technique, 280-ms gantry rotation time, and heart rate adaptive pitch of Automated tube current modulation (CareDose 4D, Siemens Healthcare) was used. One tube of the dual-source CT system was operated with 140 reference mas per rotation at 140 kvp using an additional tin filter, and the second tube was operated with 165 reference mas per rotation at 100 kvp. Data were acquired in a craniocaudal direction. A bolus-triggering technique was used with a threshold of 70 HU in the thoracic aorta and an additional delay of 2 seconds. Stress acquisition was performed after a 2- to 5-minute infusion of adenosine (140 μg/kg/min; Adenoscan, Astellas) using an automatic perfusion pump or a single injection of 0.4 mg of regadenoson (Lexiscan, Astellas) under physician supervision, using a second IV line placed in the contralateral antecubital vein. Stress acquisition was started when an adequate hemodynamic response to adenosine or regadenoson (heart rate increase > 10 beats/min or systolic blood pressure decrease > 10 mm Hg) was observed. A blood pressure cuff was placed on the arm of the contrast agent injection, to avoid interference with the administration of adenosine, in combination with a continuous ECG to monitor the patient heart rate and the response to adenosine or regadenoson administration. The attending physicians had aminophylline for adenosine receptor antagonism and nitroglycerine for persistent chest pain readily available, and a fully equipped resuscitation trolley with defibrillator was easily accessible. For rest DECT examinations, patients with resting heart rates equal to or greater than 65 beats/min and those who did not readily return to their resting heart rate of less than 65 beats/min after completion of the stress portion received up to 15 mg of IV metoprolol tartrate (Lopressor, Novartis) before their rest examination. Stress and rest examinations were enhanced with 80 ml of iopamidol (370 mg I/mL Isovue, Bracco) for each study followed by 50 ml of saline. Flow rate was 6 ml/s, whenever possible. Late-enhancement acquisition was performed 6 minutes after stress acquisition without application of additional contrast material. CT Image Reconstruction Merged DECT images were reconstructed with equal contributions from the 140-kVp dataset and the 100-kVp dataset at 1.5-mm reconstruction thickness, using a dedicated DECT kernel (D30f). Both systolic and diastolic series were reconstructed. Iodine distribution maps were generated using the heart PBV postprocessing algorithm of the DECT application on a workstation (Multimodality Workplace, version VE36A, Siemens Healthcare). The resulting color-coded iodine maps were then superimposed onto grayscale multiplanar reformats of the virtual unenhanced datasets of the myocardium in short- and long-axis views of the left ventricle (Fig. 1). SPECT Examination SPECT was performed after IV administration of tetrofosmin ( 99m Tc). In summary, nuclear myocardial perfusion imaging was acquired with a single-day rest and stress protocol. Radionuclide activities of 370 MBq and 1110 MBq were administered IV at rest and stress, respectively. Ergometric stress testing was performed with the use of the Bruce treadmill protocol. Pharmacologic stress testing with adenosine or regadenoson was performed if there were contraindications for ergometric testing or in the event of an inadequate AJR:203, July 2014 W71

3 De Cecco et al. A D B E G H I Fig year-old man with history of coronary revascularization and recent onset of chest discomfort. A C, Pharmacologic stress dual-energy myocardial iodine distribution maps in four-chamber (A), long-axis (B), and short-axis (C) views show homogeneous iodine distribution consistent with normal myocardial perfusion. D F, Stress SPECT images in four-chamber (D), long-axis (E), and short-axis (F) views also show normal myocardial perfusion. G and H, Curved multiplanar reconstructions of coronary CT angiography show patent stents (arrowheads) in left anterior descending artery (G) and circumflex branch (H) and some eccentric calcifications without significant stenosis. I, Right coronary artery shows no evidence of coronary artery disease. Catheter angiography was not performed in this patient. C F W72 AJR:203, July 2014

4 A D B E G H I Fig year-old man with diabetes who experienced shortness of breath after mild exercise. A C, Pharmacologic stress dual-energy CT myocardial iodine distribution maps in four-chamber (A), long-axis (B), and short-axis (C) views show circumscribed area of decreased iodine content (arrows) in apicoanterior left ventricular myocardium, consistent with perfusion defect. D F, Stress SPECT images in four-chamber (D), long-axis (E), and short-axis (F) views confirm area of ischemia (arrows) in apicoanterior wall of left ventricle. G I, Catheter angiography in right anterior oblique view (G), coronary CT angiography in curved multiplanar reconstruction (H), and volume-rendered image (I) show critical stenosis of proximal portion of left anterior descending artery (arrows), which was subsequently treated with stent. C F AJR:203, July 2014 W73

5 De Cecco et al. exercise stress test. A triple-head camera system (Vertex 601, collimator VXGP, Philips Healthcare) with attenuation correction was used for ECGgated data acquisition. Emission data were reconstructed using a gaussian smoothing filter with scatter correction, followed by iterative reconstruction (FLASH3D, Siemens Healthcare). Short-axis, horizontal long-axis, and vertical long-axis images were automatically generated. In cases when the software failed to detect left ventricular contours, manual contours correction was performed by an experienced technologist. Also, if there was significant patient motion noted during review of raw projections, motion correction software was applied. Analysis of SPECT Images To establish a reference standard for hemodynamically significant stenosis, SPECT examinations were interpreted for perfusion defects by two experienced readers (one nuclear medicine physician and one cardiologist) in consensus. Images were analyzed on a dedicated console using commercially available software (Syngo VA60A, Siemens Healthcare). Evidence of ischemia was recorded by visual comparison of rest and stress SPECT perfusion scans. Perfusion defects were visually rated as reversible (only present at stress), fixed (present in both rest and stress images), and mixed (more pronounced at stress, partly reversible at rest). Readers were blinded to the results of DECT and catheter angiography examinations. Analysis of Cardiac Catheterization Images To establish a reference standard for morphologically significant coronary artery stenosis, angiograms obtained from these cardiac catheterizations were interpreted for the presence of significant coronary artery stenosis in consensus by two experienced interventional cardiologists. Catheter angiograms were viewed on a dedicated workstation (Vue Cardio PACS, Carestream Health). A significant coronary stenosis was defined as 50% or more luminal narrowing. CT Image Analysis Analysis of coronary CT angiography Coronary CTA datasets were evaluated by two readers with extensive experience in cardiac CT for the presence of significant coronary artery stenosis defined as luminal narrowing greater than 50%. Clinical coronary CTA analysis of coronary artery morphology for stenosis detection and grading was performed visually using dedicated software (Syngo.via, Siemens Healthcare) on the basis of a combination of transverse sections and curved multiplanar reformats of the target vessels. Visual analysis of dual-energy CT myocardial iodine maps From each set of DECT raw data, one image series was reconstructed only on the basis of the 80-kV x-ray spectrum and another only on the basis of the 140-kV x-ray spectrum on the workstation. The myocardial iodine distribution was analyzed according to the unique x-ray absorption characteristics of this element at different kilovoltage levels. The resulting colorcoded iodine maps were then superimposed onto gray-scale multiplanar reformats of the myocardium in short- and long-axis views of the left ventricle. The resulting images were displayed using the Heart Perfused Blood Volume application of the DECT image postprocessing software. Two experienced readers in consensus analyzed all DECT studies for myocardial iodine defects using the American Heart Association 17 segmental model. Perfusion assessment was performed using both the stress and rest images. Readers were blinded to the results of SPECT and catheter angiography examinations. Myocardial perfusion defects on DECT iodine maps were defined as circumscribed areas of decreased or absent iodine content within the left ventricular wall, relative to the remainder of the myocardium. Rest and stress iodine distribution maps were viewed side-by-side and were assessed for the presence of perfusion defects. If present, perfusion defects were visually rated as reversible (only present at stress), fixed (present in both rest and stress images), and mixed (more pronounced at stress, partly reversible at rest). The beam-hardening artifacts in the dual-energy iodine distribution maps in our study were overall mild and could readily be distinguished from true perfusion defects because of their typical location adjacent to dense contrast material, streaklike appearance, and lack of correlation with coronary territories. In addition, the delayed acquisition images for each patient were viewed in short- and long-axis views of the left ventricle and were assessed for the presence of late iodine enhancement of the left ventricular wall. Late enhancement was recorded as present or absent for each patient. Estimation of Radiation Dose The CT dose index and dose-length product were recorded from patient protocols. Effective radiation dose was calculated using a standard conversion factor of for adult chest CT [12]. Statistical Analysis Catheter angiography was used as the reference standard for the presence of a morphologically significant coronary stenosis, which was defined as more than 50% luminal narrowing. SPECT examination was used as the reference standard for the detection of myocardial perfusion defects when determining hemodynamic significance of lesions. Against these reference standards, the diagnostic performance of coronary CTA alone, DECT myocardial perfusion assessment alone, and the combined assessment (both positive and either positive) were evaluated. For each comparison, we calculated per-patient sensitivity and specificity. ROC curve statistics were performed, and the AUC and the pertinent p value were calculated. A p value less than 0.05 was considered statistically significant. All statistical analyses were conducted using statistical software (SPSS Statistics version 21, IBM). Results Prevalence of Perfusion Defects on SPECT and Dual-Energy CT In 21 of 29 patients (72%), a myocardial perfusion defect was identified on SPECT. Perfusion defects were classified as fixed in 14 patients, reversible in five patients, and mixed in two patients. On DECT, perfusion defects were detected in 22 patients. DECT classified 16 perfusion defects as fixed, three as reversible, and three as mixed. In 11 of the 16 patients with fixed perfusion defects, late iodine enhancement was detected at DECT. Prevalence of Significant Coronary Artery Stenosis on Coronary CT Angiography and Catheterization Of the 25 patients with cardiac catheterization, 19 were found to have at least one significant (> 50% diameter narrowing) stenosis at invasive angiography. Coronary CTA revealed at least one significant stenosis in 23 of 29 patients. Diagnostic Value of Dual-Energy CT for the Detection of Morphologically Significant Stenosis First, we assessed the diagnostic value of DECT for detecting morphologically significant stenosis, defined as greater than 50% luminal narrowing on catheterization (n = 25; Table 2). The presence of a significant stenosis on coronary CTA predicted the presence of a significant stenosis on catheterization with 95% sensitivity and 50% specificity. A perfusion defect on DECT predicted the presence of a significant stenosis on catheter with 95% sensitivity and 50% specificity. If either coronary CTA or DECT perfusion maps, or both, were positive ( either positive ), this predicted the presence of a significant stenosis on catheter with 100% sensitivity and 33% specificity. If both coronary CTA and DECT perfusion maps were positive ( both positive ), this predicted hemo- W74 AJR:203, July 2014

6 TABLE 2: Per-Patient Test Characteristics of Dual-Energy CT (DECT) for Detection of Morphologically Significant Stenosis Evaluation Protocol Sensitivity (%) Specificity (%) AUC p Coronary CT angiography positive (at least one stenosis > 50%) Perfusion defect on DECT myocardial iodine maps Either positive Both positive dynamically significant stenosis with 90% sensitivity and 67% specificity. The AUC was higher for both positive (0.78) than for coronary CTA alone (0.72), perfusion defects on DECT myocardial iodine maps alone (0.72), and either positive (0.67). On ROC analysis, the diagnostic value for the prediction of perfusion defects on SPECT was only significant for both positive (p = 0.04), but not for coronary CTA alone (p = 0.11), perfusion defects on DECT myocardial perfusion maps alone (p = 0.11), and either positive (p = 0.23). Diagnostic Value of Dual-Energy CT for the Detection of Hemodynamically Significant Stenosis Next, we assessed the diagnostic value of DECT for the detection of hemodynamically significant stenosis, defined as a perfusion defect on SPECT (n = 29; Table 3). The presence of significant stenosis on coronary CTA predicted the presence of a perfusion defect on SPECT with 91% sensitivity and 38% specificity. A perfusion defect on DECT predicted the presence of a perfusion defect on SPECT with 95% sensitivity and 75% specificity. If either coronary CTA or DECT perfusion maps or both were positive ( either positive ), this predicted the presence of a perfusion defect on SPECT with 100% sensitivity and 38% specificity. If both coronary CTA and DECT perfusion maps were positive ( both positive ) (Fig. 2), this predicted hemodynamically significant stenosis with 86% sensitivity and 75% specificity. The AUCs were significantly higher for perfusion defects on DECT myocardial iodine maps (0.85) and for both positive (0.80) than for coronary CTA alone (0.64) and either positive (0.69). On ROC analysis, the diagnostic value for the prediction of perfusion defects on SPECT was only significant for perfusion defects on DECT myocardial perfusion maps (p < 0.01) and both positive (p = 0.01), but not for coronary CTA alone (p = 0.25) or either positive (p = 0.12). Effective Radiation Dose of Dual-Energy CT Examination Mean CT dose indexes were 24, 29, and 20 mgy, and mean dose-length products were 398, 452, and 310 mgy cm for rest, stress, and delayed DECT, respectively. The corresponding average effective radiation dose equivalent from rest, stress, and delayed DECT were 5.8, 6.6, and 4.5 msv, respectively. The mean radiation dose from all three acquisitions was 16.9 msv. TABLE 3: Per-Patient Test Characteristics of Dual-Energy CT for Detection of Hemodynamically Significant Stenosis Evaluation Protocol Sensitivity (%) Specificity (%) AUC p Coronary CT angiography positive (at least one stenosis > 50%) Perfusion defect on myocardial < 0.01 iodine maps Either positive Both positive Discussion In high-risk patients, blooming artifacts from severe coronary calcifications can impair the visualization of the coronary lumen, thus reducing the diagnostic accuracy of coronary CTA for significant stenosis. The resulting reduction in coronary CTA specificity frequently leads to further functional testing or to direct referral to coronary catheterization. In our study, we found a per-patient specificity of 50% and 38% for coronary CTA, compared with catheterization and SPECT, respectively. This is in line with a recent meta-analysis analyzing coronary CTA performance in patients with an elevated calcium score, which showed a significant decrease in specificity from 88.2% to 50.6% when the calcium score range moved from to [13]. This result was expected, because it is generally accepted and also has been our experience that coronary CTA performs better in patients with a low-to-intermediate likelihood of having CAD than in high-risk patients. Functional imaging, on the other hand, is less likely to suffer in patients with significant CAD burden. Thus, SPECT is superior for assessing the hemodynamic relevance of coronary plaques in high-risk patients, overcoming this intrinsic limitation of anatomic diagnostic techniques. In our study, adding myocardial perfusion assessment to coronary CTA significantly increased the specificity for coronary artery stenosis. Where significant stenosis on coronary CTA was associated with a perfusion defect on DECT myocardial perfusion maps, the specificity was 67% and 75% compared with catheterization and SPECT, respectively. On ROC analysis, the both positive approach had the highest discriminatory power for the detection of morphologically significant coronary artery stenosis using catheterization as the reference standard, outperforming both coronary CTA-only and DECT-only myocardial perfusion assessment. With SPECT as the reference standard for hemodynamically significant stenosis, both the both positive approach and the DECT myocardial perfusion maps alone had a similarly high discriminatory power. This reflects that coronary CTA, as an anatomic method, is more similar to coronary catheterization, and that DECT perfusion, as a functional test, shows a stronger correlation with SPECT. In the first clinical study on adenosinestress DECT myocardial perfusion imaging, Ruzsics et al. [3] reported a per-segment sensitivity of 92% and 93% specificity. Wang et al. [8] reported 68% sensitivity and 93% specificity. Using adenosine-stress MRI as the reference standard, Ko et al. [7] found 89% sensitivity and 76% specificity of rest and stress DECT for the detection of reversible perfusion defects. Our results are likely influenced by a high prevalence of CAD in the selected population; in fact, the ma- AJR:203, July 2014 W75

7 De Cecco et al. jority of patients in our study had a known history of CAD or myocardial infarction or both. Also, we chose to perform a per-patient analysis rather than a per-segment analysis, because this more directly relates to clinical implications of the diagnostic test, whether or not a patient will be referred for catheter angiography or nuclear stress testing. The true value of DECT myocardial perfusion imaging can only be appreciated by not considering it as a stand-alone test, such as SPECT, but as the functional complement to an anatomic evaluation of the coronary arteries, which should be applied in cases where coronary CTA is unable to discriminate flow-limiting stenosis from nonobstructive disease. A preliminary evaluation of the incremental value of DECT has recently analyzed the combination of rest-only DECT myocardial perfusion and coronary CTA in a low-risk population, showing a sensitivity of 90% and specificity of 86% for identifying 50% or greater coronary stenosis [8]. However, rest-only DECT myocardial perfusion fails to unveil the full potential of the technique, because reversible perfusion defects are detected only with the addition of a stress phase. Moreover, the true clinical value of the perfusion technique is likely to be limited in a population with a low prevalence of CAD. Thus, the value of DECT perfusion can be assessed only using the complete rest and stress protocol in a high-risk population with a considerable number of false-positive coronary CTAs. A previous study has shown the superior cost-effectiveness of utilizing coronary CTA as a gatekeeper to catheter angiography in a population with a high prevalence of CAD compared with myocardial perfusion techniques [14]. It may be hypothesized that the combined anatomic and functional information offered by DECT could further increase the cost-effectiveness of the technique in high-risk populations. In the first generation of dual-source CT scanners used for cardiac DECT, the dualenergy mode was limited by a decreased temporal resolution of 165 ms, instead of 83 ms, which could reduce the diagnostic performance in the detection of coronary stenosis. However, this historical disadvantage of cardiac DECT has been overcome in the second-generation dual-source CT, which offers the full temporal resolution of 75 ms also in dual-energy mode, thus not affecting the visualization of the coronary vasculature [15]. The rest DECT acquisition can be performed at the same radiation dose as a standard coronary CTA study [16]. For this reason, the rest DECT acquisition does not have disadvantages for the patient in comparison with a conventional coronary CTA study, while providing additional information on the myocardial blood pool distribution. The full cardiac DECT protocol with rest, stress, and delayed acquisition adds additional radiation exposure compared with a conventional coronary CTA. However, if used as an alternative to SPECT for the evaluation of myocardial perfusion, the comprehensive assessment of coronary anatomy and myocardial perfusion with DECT may actually decrease the total radiation exposure of the patient. Cardiac DECT is a very recent technique, and the experience and evidence regarding the optimal interpretation of DECT myocardial iodine distribution maps are limited. The optimal diagnostic criteria of DECT myocardial iodine maps for the detection of fixed or reversible ischemia remain to be established. In particular, it has been reported that DECT rest acquisition alone can detect the presence of reversible perfusion defects [3, 6, 8], secondary to an intrinsic vasodilatory effect of the iodinated contrast medium [6]. If confirmed, this effect could cause a misclassification of perfusion defects by DECT compared with SPECT. Further investigations are needed to determine how this phenomenon is best understood and how it should be accounted for in the interpretation of cardiac DECT examinations. The results of this study should be considered within the context of the study design and its limitations. First, the number of patients in this initial study was limited. In particular, the number of patients with a negative reference standard was very low in this high-risk population. 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