In order to bring you the best possible user experience, this site uses Javascript. If you are seeing this message, it is likely that the Javascript option in your browser is disabled. For optimal viewing of this site, please ensure that Javascript is enabled for your browser.

The free consultation period for this content is over.

It is now only available year-round to EACVI Silver Members, Fellows of the ESC and Young combined Members

Redefining assessment of adenosine stress response using CMR perfusion mapping: An alternative to splenic switch off

Session Rapid Fire Abstract 3: stress CMR: utility in coronary artery disease and beyond

Speaker Tushar Kotecha

Congress : EuroCMR 2019

  • Topic : imaging
  • Sub-topic : Stress CMR
  • Session type : Rapid Fire Abstracts
  • FP Number : 302

Authors : T Kotecha (London,GB), JM Monteagudo (London,GB), A Martinez-Naharro (London,GB), C Little (London,GB), LIZA Chacko (London,GB), JM Brown (London,GB), D Knight (London,GB), PN Hawkins (London,GB), JM Moon (London,GB), H Xue (Bethesda,US), PN Kellman (Bethesda,US), N Patel (London,GB), T Lockie (London,GB), RD Rakhit (London,GB), M Fontana (London,GB)

T Kotecha1 , JM Monteagudo1 , A Martinez-Naharro1 , C Little1 , LIZA Chacko1 , JM Brown1 , D Knight1 , PN Hawkins1 , JM Moon2 , H Xue3 , PN Kellman3 , N Patel1 , T Lockie1 , RD Rakhit1 , M Fontana1 , 1Royal Free Hospital , Cardiology - London - United Kingdom of Great Britain & Northern Ireland , 2Barts Health NHS Trust - London - United Kingdom of Great Britain & Northern Ireland , 3National Institutes of Health - Bethesda - United States of America ,

European Heart Journal - Cardiovascular Imaging ( 2019 ) 20 ( Supplement 2 ), ii221


The splenic switch off (SSO) sign is routinely used in clinical practice to assess adequacy of adenosine stress during perfusion CMR studies with absence of SSO suggested as evidence of suboptimal stress. Myocardial perfusion mapping is a novel tool that provides pixelwise maps of myocardial blood flow (MBF), allowing for measurement of increase in MBF in response to adenosine at a regional level.


To assess the performance of peak stress MBF (SMBFmax, the myocardial segment with the maximum stress MBF value) measured using perfusion maps to assess for maximal stress compared to the SSO sign. 


In total, 216 subjects were recruited to the study. Twenty-two healthy controls underwent stress perfusion CMR in order to assess normal increase in MBF in response to adenosine and identify threshold values for SMBFmax. A "coronary physiology cohort" of 37 patients underwent stress perfusion CMR and invasive coronary physiology assessment on the same day to compare CMR perfusion parameters to reference standard invasive measures of hyperaemia (defined as at least two out of three of: 1) ventricularisation of the distal pressure waveform, 2) disappearance of the dicrotic notch on the distal waveform, 3) separation of mean aortic and distal pressures) . Finally, a "clinical cohort" of 157 patients were studied to compare perfusion mapping parameters to SSO. 


From the healthy volunteer scans, SMBFmax >1.43ml/g/min was derived as the threshold value for hyperaemia (defined as 1.96 standard deviations below the sample mean of segments with lowest stress MBF values). This threshold was then tested in the coronary physiology cohort: 100% of patients with invasive evidence of hyperaemia demonstrated mapping values greater than the predefined threshold of SMBFmax >1.43ml/g/min, despite absence of SSO in 19% of cases (Panel A). When the threshold was applied to 157 patients who underwent adenosine stress CMR, 93% of cases had hyperaemia defined by at least one segment with SMBFmax >1.43ml/g/min compared to only 71% using SSO (Panel B). Overall there was no difference in stress perfusion parameters in those with or without SSO (SMBFmax: 2.58±0.89ml/g/min SSO vs 2.54±1.04ml/g/min no SSO, p=0.84; myocardial perfusion reserve: 2.69±1.06 SSO vs 2.87±1.14 no SSO, p=0.35). Increase in heart rate >16bpm was able to predict stress response (SMBFmax >1.43ml/g/min) with sensitivity 63% and specificity 91% (AUC 0.87, p<0.001) and performed better than the SSO sign (AUC 0.62, p<0.001 for comparison of methods). We developed a diagnostic algorithm based on perfusion maps to assess stress response (Panel D).

Conclusion Adenosine-induced increase in MBF measured using perfusion mapping can be used assess hyperaemic response during stress CMR studies identify studies with sub-maximal stress.

The free consultation period for this content is over.

It is now only available year-round to EACVI Silver Members, Fellows of the ESC and Young combined Members

Based on your interests

Three reasons why you should become a member

Become a member now
  • 1Access your congress resources all year-round on the New ESC 365
  • 2Get a discount on your next congress registration
  • 3Continue your professional development with free access to educational tools
Become a member now

Our sponsors

ESC 365 is supported by Bayer, Boehringer Ingelheim and Lilly Alliance, Bristol-Myers Squibb and Pfizer Alliance, Novartis Pharma AG and Vifor Pharma. The sponsors were not involved in the development of this platform and had no influence on its content.

logo esc

Our mission: To reduce the burden of cardiovascular disease

Who we are