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Overview

Cardiac imaging should begin with the clinical question rather than the modality. Each test provides different information about anatomy, physiology, perfusion, tissue composition, and hemodynamics.

Imaging Modalities

  • Echocardiography — cardiac structure, valve disease, ventricular function, and hemodynamics
  • Nuclear Cardiology — myocardial perfusion, viability, amyloidosis, inflammation, and ventricular function
  • Cardiac CT — coronary anatomy, calcium, cardiac structures, and procedural planning
  • Cardiac MRI — ventricular function, tissue characterization, flow, viability, and cardiomyopathy
  • Diagnostic Catheterization — invasive coronary assessment and direct hemodynamic measurement

Choosing a Test

Clinical question Common first test
Ventricular or valve function Echocardiography
Suspected obstructive CAD CCTA or functional stress imaging
Ischemia and perfusion PET, SPECT, stress echo, or stress CMR
Cardiomyopathy or myocardial tissue Cardiac MRI
Coronary anatomy Cardiac CT or invasive angiography
Cardiac amyloidosis Echo/CMR plus bone-avid tracer imaging
Endocarditis or intracardiac thrombus TTE followed by TEE when indicated
Definitive pressure or resistance measurement Cardiac catheterization

Test selection should account for pretest probability, image quality, renal function, rhythm, implanted devices, radiation exposure, local expertise, and whether the result will change management.

Core Principles

  • Define the question before ordering the test.
  • Review prior imaging before repeating a study.
  • Use the lowest-risk test that can answer the question reliably.
  • Recognize when findings require confirmation with another modality.
  • Interpret imaging within the complete clinical context.
  • Compare serial studies using consistent techniques whenever possible.

Resources

  1. Multimodality Imaging in Cardiology — EACVI Task Force
  2. Coronary CT for Cardiology Fellows — Marc Katz, MD
  3. American Society of Echocardiography Guidelines
  4. American Society of Nuclear Cardiology Guidelines
  5. Society for Cardiovascular Magnetic Resonance Guidelines
  6. Society of Cardiovascular Computed Tomography Guidelines