Coronary artery disease (CAD) is one of the leading causes of death in the world. In the United States alone, it is estimated that approximately every 25 seconds, a new CAD event will occur, and approximately every minute, someone will die of one. The detection of CAD during in its early stages is very critical to reduce the mortality rates. Magnetic resonance imaging of myocardial perfusion (MR-MPI) has been receiving significant attention over the last decade due to its ability to provide a unique view of the microcirculation blood flow in the myocardial tissue through the coronary vascular network. The ability of MR-MPI to detect changes in microcirculation during early stages of ischemic events makes it a useful tool in identifying myocardial tissues that are alive but at the risk of dying. However this technique is not yet fully established clinically due to fundamental limitations imposed by the MRI device physics. The limitations of current MRI schemes often make it challenging to simultaneously achieve high spatio-temporal resolution, sufficient spatial coverage, and good image quality in myocardial perfusion MRI. Furthermore, the acquisitions are typically set up to acquire images during breath holding. This often results in motion artifacts due to improper breath hold patterns. This dissertation deals with developing novel image reconstruction methods in conjunction with non-Cartesian sampling for the reconstruction of dynamic MRI data from highly accelerated / under-sampled Fourier measurements. The reconstruction methods are based on adaptive signal models to represent the dynamic data using few model coefficients. Three novel adaptive reconstruction methods are developed and validated: (a) low rank and sparsity based modeling, (b) blind compressed sensing, and (c) motion compensated compressed sensing. The developed methods are applicable to a wide range of dynamic imaging problems. In the context of MR-MPI, this dissertation show feasibilities that the developed methods can enable free breathing myocardial perfusion MRI acquisitions with high spatio-temporal resolutions ( < 2mm x 2mm, 1 heart beat) and slice coverage (upto 8 slices).

Les maladies cardiovasculaires représentent la première cause de mortalité dans le monde, et un tiers de ces décès sont causés par la maladie coronaire et la rupture de plaques d'athérome vulnérables. L'altération hétérogène de la microcirculation coronaire est un phénomène précoce lié à de nombreux facteurs de risque cardiovasculaire qui peut fortement présager du développement ultérieur de la maladie coronaire, et conduire à l'apparition d'une hétérogénéité de la perfusion myocardique. La médecine nucléaire permet l'étude de la perfusion myocardique en routine clinique grâce à la réalisation de scintigraphies après injection d'un traceur radioactif du débit sanguin coronaire. L'analyse des images scintigraphiques de la perfusion permet actuellement le dépistage de l'ischémie myocardique, mais la capacité de la technique à mesurer l'hétérogénéité de la perfusion dans des zones apparemment normalement perfusées est inconnue. La première partie de cette thèse porte sur une étude clinique rétrospective visant à déterminer la faisabilité de la quantification de l'hétérogénéité de la perfusion du myocarde mesurée par tomographie d'émission monophotonique (TEMP) au Thallium-201 chez des patients diabétiques par rapport à des sujets sains. L'étude clinique a démontré la capacité du Thallium-201 en imagerie TEMP de routine à quantifier une hétérogénéité de la perfusion du myocarde plus importante chez des patients diabétiques par rapport à des individus normaux. La seconde partie de cette thèse teste l'hypothèse que l'hétérogénéité de la perfusion du myocarde pourrait être quantifiée en imagerie du petit animal TEMP au Thallium-201 et/ou au Technetium-99m-MIBI par une étude expérimentale chez deux modèles animaux de diabète, et serait en corrélation avec des altérations histologiques. L'absence de différence d'hétérogénéité de la perfusion myocardique entre les animaux diabétiques et contrôles suggère que les modèles animaux sont peu adaptés, ou que la technologie actuellement disponible ne semble pas satisfaisante pour obtenir des résultats similaires à l'étude clinique. / Cardiovascular diseases are the leading cause of mortality worldwide, and third of these deaths are caused by coronary artery disease and rupture of vulnerable atherosclerotic plaques. The heterogeneous alteration of the coronary microcirculation is an early phenomenon associated with many cardiovascular risk factors that can strongly predict the subsequent development of coronary artery disease, and lead to the appearance of myocardial perfusion heterogeneity. Nuclear medicine allows the study of myocardial perfusion in clinical routine through scintigraphic scans performed after injection of a radioactive tracer of coronary blood flow. Analysis of scintigraphic perfusion images currently allows the detection of myocardial ischemia, but the ability of the technique to measure the perfusion heterogeneity in apparently normally perfused areas is unknown. The first part of this thesis focuses on a retrospective clinical study to determine the feasibility of myocardial perfusion heterogeneity quantification measured by Thallium-201 single photon emission computed tomography (SPECT) in diabetic patients compared with healthy subjects. The clinical study has demonstrated the ability of routine thallium-201 SPECT imaging to quantify greater myocardial perfusion heterogeneity in diabetic patients compared with normal subjects. The second part of this thesis tests the hypothesis that the myocardial perfusion heterogeneity could be quantified in small animal SPECT imaging by Thallium-201 and/or Technetium-99m-MIBI in an experimental study using two animal models of diabetes, and is correlated with histological changes. The lack of difference in myocardial perfusion heterogeneity between control and diabetic animals suggests that animal models are poorly suited, or that the technology currently available does not seem satisfactory to obtain similar results as the clinical study.

A angiografia coronariana por tomografia computadorizada (ACTC) é um exame bem estabelecido no diagnóstico da doença arterial coronariana. Entretanto, segmentos coronarianos submetidos a implante de stent podem apresentar limitação na avaliação luminal. O objetivo deste estudo é avaliar o valor adicional da perfusão miocárdica por tomografia computadorizada (PMTC) à avaliação anatômica isolada pela ACTC em portadores de stent, tendo o cateterismo (CATE) como referência. Quarenta e seis pacientes (56,9±7,2 anos, 28 homens) com indicação clínica de CATE em até 60 dias foram submetidos à avaliação combinada de ACTC e PMTC, por meio de tomógrafo de 64 detectores (Aquillion 64, Toshiba). A aquisição foi iniciada com a fase de estresse (PMTC) usando-se dipiridamol a 0,56mg/kg/4min e 60ml de contraste a 3ml/s, seguido de reversão com aminofilina 240mg e metoprolol (até 20mg). Em seguida, realizou-se a ACTC com 80-90ml de constraste a 5ml/s. Os dados da PMTC, da ACTC, e do CATE foram analisados por dois observadores independentes, sem informações clínicas dos pacientes. Primariamente analisou-se a ACTC, seguida da avaliação da PMTC. Concluída esta fase, os observadores tinham a possibilidade de reclassificar os segmentos coronarianos submetidos a stent cuja avaliação estivesse limitada ou inadequada por artefatos. A dose total média de radiação foi 15,83±4,93 mSv e todos os exames foram adequados. Um total de 129 segmentos coronarianos foi avaliado na ACTC, bem como os respectivos territórios miocárdicos pela PMTC. Destes, 54 territórios (42%) eram relacionados à presença de stents, sendo 19 com stents de avaliação adequada e 23 com avaliação luminal limitada, porém possível, e 12 segmentos de avaliação inadequada (sem possibilidade de avaliação luminal). Os valores de sensibilidade, especificidade, valor preditivo positivo, valor preditivo negativo e acurácia para a ACTC isolada nos territórios com stents foram de, respectivamente: 85%, 76%, 85%, 76% e 81%, e com o uso combinado da ACTC + PMTC foram de, respectivamente 88%, 95%, 97%, 83% e 92% (p=0,0314). Nos territórios com stent e avaliação luminal prejudicada (limitada ou inadequada) os valores para análise da ACTC isolada foram de, respectivamente: 83%, 71%, 75%, 80% e 77% e após a análise da ACTC + PMTC foram de, respectivamente: 89%, 94%, 94%, 89% e 92% (p = 0,0441). A avaliação combinada da ACTC + PMTC permitiu melhorar a acurácia diagnóstica da avaliação de obstrução coronariana significativa em pacientes portadores de stents, comparativamente à avaliação isolada da ACTC / Coronary computed tomography angiography (coronary CTA) is a well established examination in the diagnosis of coronary artery disease (CAD). However, the segments with prior coronary stent implantation may have limited luminal evaluation. The aim of this study is to assess the incremental value of myocardial computed tomography perfusion (myocardial CTP) to the anatomical assessment by coronary CTA alone in patients with stents, using catheterization (CAT) as a reference method. Forty-six patients (56.9 ± 7.2 years, 28 men) referred to CAT by clinical indication within 60 days, were evaluated with combined evaluation of coronary CTA and myocardial CTP through 64-detector CT scanner (Aquillion 64, Toshiba). The acquisition protocol began with the stress phase (myocardial CTP), using dipyridamole to 0.56 mg/kg/4min and 60ml of contrast (3ml/s), followed by a bolus of aminophylline 240 mg and metoprolol (up to 20mg). After, it was performed the coronary CTA wih 80-90ml of contrast (5 ml/s). Data from the myocardial CTP, coronary CTA and CAT were analyzed by two independent observers, with no knowledge to clinical information. The observers reviewed the coronary CTA findings, and in a second time performed the evaluation of myocardial CTP. So, they had the possibility to reclassify segments with coronary stent that were considered with limited or inadequate assessment due to artifacts. Mean total dose of radiation was 15.83 ± 4.93 mSv, and all examinations were interpretable. A total of 129 coronary segments were evaluated by coronary CTA, and also were their correspondent myocardial territories by myocardial CTP. Of these, 54 territories (42%) were related to the presence of stents, 19 stents with adequate evaluation, 23 with limited evaluation, but possible, and 12 with inadequate evaluation (no luminal assessment possible). The sensitivity, specificity, positive predictive value, negative predictive value and accuracy for the coronary CTA in territories with stents were respectively: 85%, 76%, 85%, 76% and 81%, and the combined use of coronary CTA + Myocardial CTP were respectively 88%, 95%, 97%, 83% and 92% (p=0.0314). In territories with impaired luminal stent evaluation (limited or inadequate), the values for analysis of coronary CTA alone were: 83%, 71%, 75%, 80% and 77%, and after analysis of myocardial CTP were, respectively: 89%, 94%, 94%, 89% and 92% (p = 0.0441). The combined evaluation of the coronary CTA and myocardial CTP has improved the diagnostic accuracy of the evaluation of significant coronary obstruction in patients with stents, compared to the assessment of coronary CTA alone

Ejektionsfraktion (EF) är ett mått på den globala systoliska vänsterkammarens funktion. EF är en viktig parameter för den systoliska vänsterkammare funktionen eftersom de terapeutiska samt prognostiska fattade besluten bygger på bland annat detta mått, vilket normalt är ≥ 55 % av slutdiastolisk volym. Vid beräkning av EF används bland annat tvådimensionell (2D) ekokardiografi (2D-EKO) samt myokardscintigrafi i vila (GSPECT). Utifrån 2D-EKO erhålls EF med Biplan Simpson metoden tillämpad i fyrkammarvy och tvåkammarvy i slutdiastole och slutsystole. Med GSPECT i vila erhålls EF värden utifrån QPS och QGS bilderna efter att en automatisk utlinjering av endokardiets konturer genomförts med hjälp av Hermes Medical solution. Syftet med studien var att se om det föreligger en signifikant skillnad för uppmätt EF mellan Myokardscintigrafi (GSPECT) och 2D Ekokardiografi i vila. Studien innefattade 30 deltagare. Deltagarnas uppgifter avidentifierades och inhämtades från tidigare genomförd 2D-EKO respektive GSPECT i vila, med högst 6 månaders mellanrum av legitimerade Biomedicinsk Analytiker. Resultatet av studien förevisade ett p – värde (p=0,000) <0,1% samt r-värde (r = 0,65.) Vilket indikerar på en stark och signifikant korrelation däremot förekommer det en bristande uppnåelse av överstämmelse mellan metoderna utifrån spridningsdiagrammet som ger ( r^2= 0,42). Bland Altmandiagammet noterar att ett gott samband mellan metoderna föreligger och även så gör standardavvikelse för 2D-EKO samt GSPECT som påvisade (50.1±¬¬10,8) respektive (49,1± 15,1). Studien förevisade goda övergripande korrelationer mellan EF härstammande från 2D-EKO och GSPECT. Sammantaget visade studien att metoderna överensstämmer med varandra vid mätning av EF. / Ejection fraction (EF) is a measure of the global systolic left chamber function. EF is a significant parameter for the systolic left ventricle function since therapeutic and prognostic conclusions are based on the left chamber ejection fraction. EF is normally ≥ 55% of the end-diastolic volume. Left ventricle ejection fraction can be determined non-invasively by 2D echocardiography (2D – ECHO) and gated single photon emission computed tomography. Based on 2D echocardiography (2D-ECHO), EF was obtained using the biplane Simpson method applied in four-chamber view and two- chamber views in both end diastole and end systole. With myocardial perfusion (GSPECT), EF values were obtained based on the QPS- and QGS- images after an automatic orientation of endocarditis contours were carried out by Hermes Medical solution. The purpose of this report was to see if there is a significant difference in (EF) between (GSPECT) and (2D-ECHO) at rest. The study included 30 participants. EF values were attained by licensed biomedical scientist. Participants' data were de-characterized and obtained from previously performed Echocardiography (2D-ECHO) and myocardial perfusion (GSPECT) at rest examination at intervals of no more than 6 months. The outcomes of the study showed (p=0.000) <0.1% and (r = 0.65) thus representing a strong and significant correlation, however there is a lack of consistency between the methods based on the scattering chart that gives (r^2 = 0.42). Bland Altman's illustration state that a good correlation between the methods exists and so does standard deviation for 2D-ECHO and Myocardial perfusion (GSPECT) as demonstrated (50.1±10.8) and (49.1±15.1) respectively. The study showed good overall correlations between EF derived from (2D ECHO) and Myocardial perfusion (GSPECT). In conclusion, the statistics demonstrated that the methods are comparable to each other when measuring EF.

Les nouvelles gamma-caméras à semi-conducteurs utilisant des détecteurs au CZT sont dédiées aux explorations cardiaques. Leurs sensibilité, résolution spatiale et en énergie nettement améliorées comparativement aux gamma-caméras conventionnelles sont une révolution en médecine nucléaire. Ces gamma-caméras utilisent de nouvelles géométries d’acquisition, de nouveaux algorithmes de reconstruction, et ouvrent de nouvelles perspectives dans les études simultanées en double-isotope de l’123I et du 99mTc, dont les pics énergétiques sont proches.Nous avons étudié l’impact de l’amélioration de la résolution en énergie en comparant deux modèles de gamma-caméras à détecteurs semi-conducteurs aux gamma-caméras conventionnelles. A l’aide d’études sur fantômes anthropomorphes et chez des patients porteurs d’insuffisance cardiaque, notre travail s’est concentré sur les acquisitions scintigraphiques (i) de la fonction ventriculaire gauche (99mTc) en présence d’123I, (ii) de la perfusion myocardique (99mTc) en présence d’123I (innervation), et (iii) du rapport cardiomédiastinal de la fixation d’123I- métaiodobenzylguanidine (123I-MIBG) lors d’acquisitions double-isotope (123I-MIBG/99mTc- tétrofosmine) chez les patients souffrant d’insuffisance cardiaque.Nos résultats montrent que la meilleure résolution en énergie des gamma-caméras CZT permet en étude double-isotope (i) une évaluation de la FEVG et du mouvement régional dans les différentes fenêtres d'énergie (123I ou 99mTc) et les types d'acquisition (simple- vs double-isotope), (ii) une évaluation simultanée et combinée de la perfusion (99mTc) et de l’innervation (123I) du myocarde, et (iii) l’évaluation du rapport cardiomédiastinal de la fixation d’123I-MIBG. Chacune de ces trois parties a fait l’objet d’une publication. / New dedicated-cardiac cameras using CZT detectors have dramatically transformed the routine of myocardial perfusion imaging. With a better count detection sensitivity, an improved spatial and energy resolution, they potentially enable combined assessment of myocardial innervation (123I) and perfusion (99mTc) within a single imaging session. These cameras images with different sharpness and contrast-to-noise ratios.Using two CZT cameras with anthropomorphic phantom, and clinical studies in heart failure patients, our work focused on (i) the left ventricular function assessment within the 99mTc window in presence of 123I, (ii) the evaluation of regional myocardial innervation (123I) and perfusion (99mTc) match and mismatch with single- (separate 123I and 99mTc acquisition) and simultaneous dual-isotope acquisitions, and (iii) the late heart-to-mediastinal ratio (HMR) of 123I-MIBG uptake determined using dual-isotope CZT acquisition with that determined using conventional planar imaging in patients with heart failure.Our results found no impact of the acquisition mode (single vs dual) or the type of CZT camera on 123I and 99mTc defect size and mismatch, LVEF, and HMR of 123I-MIBG uptake.This work provides a new step toward simultaneous dual-isotope acquisition for combined innervation, perfusion and ventricular function assessment.

Chest pain is an extremely common presenting symptom that is usually related to a cardiac cause. This case illustrates an unusual presentation of multiple myeloma as a cause of atypical chest pain. This case presentation shows the importance of having a broad differential diagnosis while evaluating patients with atypical chest pain. It also illustrates the potential role of Tc-99m sestamibi imaging as a diagnostic modality in patients with multiple myeloma.

Coronary tortuosity is the abnormal curving and twisting of the coronary arteries. Although the phenomenon of coronary tortuosity is frequently encountered by cardiologists its clinical significance is unclear. It is known that coronary tortuosity has significant influence on the hemodynamics inside the coronary arteries, but it is difficult to draw definite conclusions due to the lack of patient-specific studies and an absence of a clear definition of tortuosity. In this work, in order to investigate a relation of coronary tortuosity to such diseases as atherosclerosis, ischemia, and angina, a numerical investigation of coronary tortuosity was performed. First, we studied a correlation between a degree of tortuosity and flow parameters in three simplified vessels with curvature and zero torsion. Next, a statistical analysis based on flow calculations of 23 patient-based real tortuous arteries was performed in order to investigate a correlation between tortuosity and flow parameters, such as pressure drop, wall shear stress distribution, and a strength of helical flow, represented by a helicity intensity, and concomitant risks. Results of both idealized and patient-specific studies indicate that a risk of perfusion defects grows with an increased degree of tortuosity due to an increased pressure drop downstream an artery. According to the results of the patient-specific study, a risk of atherosclerosis decreases in more tortuous arteries - a result different from an outcome of the idealized study of arteries with zero torsion. Consequently, a modeling of coronary tortuosity should take into account all aspects of tortuosity including a heart shape that introduces additional torsion to arteries. Moreover, strength of a helical flow was shown to depend strongly on a degree of tortuosity and affect flow alterations and accompanying risks of developing atherosclerosis and perfusion defects. A corresponding quantity, helicity intensity, might have a potential to be implemented in future studies as a universal single parameter to describe tortuosity and assess congruent impact on the health of a patient. / Master of Science

No

A angiotomografia de múltiplos detectores (TC) é um exame útil no diagnóstico de doença arterial coronariana (DAC). Recentemente, a TC foi associada à perfusão miocárdica com estresse (PTC) para detectar DAC. O objetivo é comparar a perfusão miocárdica da TC, após estresse com dipiridamol, com a cintilografia miocárdica (SPECT) na detecção de estenose coronariana significativa (>70%), usando o cateterismo (CATE) como método de referência. Trinta e seis pacientes (62±8,0 anos, 20 homens) com suspeita de DAC e com SPECT positivo em menos de 2 meses foram submetidos a um protocolo de TC para avaliação da PTC e angiografia pela tomografia computadorizada (ATC). TC foi realizada em um equipamento de 64 detectores (Aquillion 64, Toshiba), com uma primeira aquisição com os seguintes parâmetros:100mA,120Kv, 32x1mm colimação e 60ml de contraste a 3ml/s, após estresse com dipiridamol (0,56mg/Kg/4min), seguida de uma aquisição de repouso/ATC após aminofilina e metoprolol (270-400mA, 120Kv,64x0,5mm e 80 ml de contraste a 5ml/s). Observadores cegos e independentes, sem conhecimento prévio dos dados clínicos ou dos exames, realizaram análise visual e quantitativa da perfusão e angiotomografia, além de análise angiográfica quantitativa (QCA) para avaliação do CATE. Todos os pacientes completaram o protocolo sem efeitos adversos com dose de radiação média de 14,7 ± 3,0 mSv e exames interpretáveis. PTC foi positiva em 27 de 36 pacientes (75%). Dos nove casos (25%) com discordâncias (PTC negativa e SPECT positivo), 6 pacientes tinham ATC ou CATE normal e 2 tinham estenose coronariana menor que 50%. Um apresentava stent pérvio e o outro um ramo diagonal com redução luminal de 50%.O terceiro paciente apresentava uma oclusão do ramo ventricular posterior da artéria coronária direita com circulação colateral detectado pela ATC e confirmado pelo CATE. A comparação entre a PTC e o SPECT em uma análise por paciente mostrou boa concordância (Kappa =0,53;p<0,001). Em 26 pacientes com CATE, como referência, os valores diagnósticos foram sensibilidade, especificidade, valor preditivo positivo, valor preditivo negativo e acurácia para a PTC 88,0; 79,3; 66,7; 93,3; 82,1% e para o SPECT 68,8; 76,1; 66,7; 77,8 e 73,1%, respectivamente. A perfusão miocárdica de repouso e estresse após dipiridamol na avaliação de doença aterosclerótica coronariana, associada à angiografia pela tomografia é factível e os resultados foram similares ao do SPECT. A combinação da informação anatômica e perfusional permite identificar os casos positivos do SPECT, sem estenose coronariana significativa. / Multidetector computed tomography is a useful method for the diagnosis of coronary artery disease. Recently, myocardial stress CT perfusion (CTP) was shown to detect myocardial ischemia. Our main objective was to evaluate the feasibility of dipyridamole stress CTP and compare to SPECT perfusion to detect significant coronary stenosis using conventional angiography (CCA) (stenosis >70%) as reference method. Thirty-six patients (62.0±8.0 years old, 20 males) with suspected CAD and < 2 months prior positive SPECT underwent a customized multidetector-row computed tomography (MDCT) protocol with rest/stress myocardial perfusion evaluation and CTA. MDCT was performed in a 64 scanner (Aquillion 64, Toshiba) with stress perfusion after 0.56mg/kg/4min of dipyridamole (100mA, 120 kV, collimation-32 x 1 mm and 60 ml of iodinated contrast) followed by aminophyline and metoprolol infusion prior to a second rest perfusion/CTA acquisition (270-400mA, 120 kV, collimation-64 x 0,5 mm and 80 ml of iodinated contrast). Independent blinded observers with no knowledge of clinical data or other exams performed visual and quantitative analysis of CTP, CTA, SPECT and quantitative coronary angiography (QCA) analysis, that was performed on CCA. All 36 patients completed the CT protocol with no adverse events, mean radiation dose of 14.7 ± 3.0 mSv and with interpretable scans. CTP was positive in 27 of 36 patients (75%). From the 9 (25%) disagreements with normal CTP and positive SPECT, 6 patients had normal CCA or CTA and 2 had no coronary stenosis > 70 %. One had patent stents and the other had a diagonal branch with mild luminal reduction at CCA. The remaining patient had an occluded right posterior lateral branch with collateral flow detect by CTA and confirmed by CCA. Good agreement was demonstrated between CTP and SPECT on a per-patient analysis (kappa 0.53). In 26 patients using CCA as reference, sensitivity, specificity, positive predictive value, negative predictive values and accuracy for CTP were 88.0, 79.3, 66.7, 93.3%, 82,1% and for SPECT 68.8, 76.1, 66.7, 77.8% and 73,1% respectively. Rest and dipyridamole-stress computed tomography myocardial perfusion is feasible and results are similar to SPECT scintigraphy. The combined anatomical information provided by computed tomography coronary angiography may allow identification of false-positives on perfusion scans.

Introdução: A presença de cálcio nas artérias coronárias identifica a existência de aterosclerose coronariana, mesmo em fases precoces. Por outro lado, a decisão quanto à melhor forma de tratamento dessa entidade baseia-se no uso de exames funcionais, em especial, a cintilografia de perfusão do miocárdio (CPM). Existem dúvidas quanto à correlação desses dois exames, o que poderia ser, ao menos em parte, explicada pelo fato dos testes avaliarem fases distintas dessa entidade. Este estudo pretende avaliar o uso de uma abordagem anatômica e funcional combinada por meio da (CPM) e tomografia computadorizada coronária com multidetectores (TCMD) na determinação do escore de cálcio (CACS) e da presença de estenoses e isquemia e examinar a associação de seus resultados entre si e com outras variáveis demográficas, clínicas e funcionais em uma população brasileira com doença arterial coronária (DAC) suspeita ou conhecida. Métodos: foram analisados, retrospectivamente, 413 pacientes que se submeteram à CPM e TCMD por indicação clínica do médico assistente, durante o ano de 2009, com intervalo menor de 90 dias, entre os dois estudos. CACS foi definido automaticamente pelo software dedicado e o escore de Agatston foi calculado de forma semiquatitativa. Na CPM e na TCMD, os resultados foram obtidos por quantificação visual semiobjetiva. A correlação dos resultados dos exames foi analisada e foram obtidos dados da evolução tardia, baseados no contato com o médico assistente ou pela análise dos registros hospitalares. Procurou-se definir os preditores da ocorrência de eventos cardiovasculares adversos na evolução. Resultados: Foram selecionados 303 pacientes (73,3% homens, média de idade de 55,8 ± 10,6 anos, intervalo: 32-86 anos). Destes, 73,3% apresentaram estudos de perfusão normal, 71,6% tinham cálcio coronário e 45,2% tinha perfusão normal e TCDM com cálcio. No grupo sem suspeita de DAC (177), houve associação entre os resultados de TCMD e SPECT com: diabetes (DM) (p=0,045), hipertensão (HAS) (p=0,032), dislipidemia (p=0,030) testes funcionais, resultado do teste (p=0,022), percentil escore de cálcio (p<0,001) e CACS (p<0,001). Nos pacientes sem DAC, houve associação com defeitos de perfusão e TCMD com cálcio que mostraram em casos de DM (30,0%) e CACS igual ou acima do percentil 75 (60,0%) e com valores acima de 400 (40,0%). O grupo com TCMD e perfusão normal apresentou maior percentual de ausência de HAS (78,6%). De outra forma, o grupo com perfusão normal e TCMD com cálcio mostrou mais pacientes com dislipidemia (42,5%) e distribuição dos percentis de CACS e CACS, semelhantes ao grupo com defeitos de perfusão e TCMD com cálcio. No grupo dos pacientes com DAC conhecida, também houve associação entre CACS e a extensão da aterosclerose coronária. Não houve associações entre os resultados da cintilografia e TCMD e outras variáveis. No subgrupo de 128 pacientes, em que se conseguiu seguimento tardio (média de 824,5 dias; DP de 385,9), aconteceram dois óbitos (1,6%), nenhum de causa cardiovascular. O evento mais frequente foi cinecoronariografia (CAT) (21,1%), seguida da angioplastia (ATC) (9,4%) e revascularizações cirúrgicas (3,1%). Não houve infarto do miocárdio (IM). De forma similar, não foram observados determinantes significativos da evolução tardia desses pacientes. Conclusões: Embora o CAC tenha sido tão frequente, como perfusão normal no SPECT, menos da metade daqueles com SPECT normal podem apresentar cálcio coronário à TCMD. Esta combinação de resultados (SPECT normal e cálcio) tinha associação com dislipidemia. Além disso, DM, CACS > 400 e percentil igual ou superior a 75% foram associados com SPECT anormal e cálcio na MDCT. A MDTC combinada ao SPECT foi capaz de detectar isquemia em pacientes com estenose coronariana conhecida, mas não havia associações entre o grau de estenose ou a presença, ou ausência de isquemia e sua extensão, com os resultados combinados. Houve uma baixa taxa de eventos no subgrupo de acompanhamento. / Background: The calcium in coronary arteries identifies the presence of coronary atherosclerosis, even in early stages. On the other hand, the decision about the best form of treatment this entity is based on the use of functional tests, in particular the myocardial perfusion scintigraphy (SPECT). There are doubts about the correlation between the results of these two exams, what could be, at least in part explained by the fact of these tests assess distinct phases of this entity. This study aims to evaluate the use of a combined functional and anatomical approach through SPECT and coronary computed tomography with multi-detectors (MDCT) in determining the calcium score (CACS),presence of stenosis or ischemia and examine the combined results with other demographic, clinical and functional variables, in a Brazilian population with suspected or known coronary artery disease (CAD). Methods: we retrospectively analyzed 413 patients who underwent to SPECT and MDCT by their physician indications during the year 2009, with less than 90 days interval between the two studies. CACS was automatically defined by dedicated software and the Agatston score was semi-automatically calculated. SPECT and MDCT results were evaluated by semi-objective visual quantification. The correlations of both tests results were analyzed and follow-up data were obtained through contact with assistant physician or analysis of hospital records. Results: We included 303 patients with suspect or known DAC who underwent to both, SPECT and MDCT (75.9 % men, mean age 55.8 ± 10.6 years; range:32-86 years); it was observed that 73,3% had normal perfusion studies, CAC was present 71,6% patients and 48.2% had normal perfusion and MDCT with calcium. In 177 patients without DAC there were association between MDCT and SPECT results and following variables: diabetes (DM) (p=0.045), hypertension (HAS) (p=0.032), dyslipidemia (p=0.030), functional test results (p=0.022), percentile of calcium score (p<0.001) and CACS (p<0.001). Patients without DAC, with perfusion defects and calcium showed more occurrences of DM (30.0%) and CACS equal to or above the 75 percentile (60.0%) and with values above 400 (40.0%). The group with normal MDCT and perfusion had higher percentage of absence of HAS (78.6%). The group with normal perfusion and MDCT with calcium had the highest percentage of patients with dyslipidemia (42.5%) and distribution of the calcium score percentiles and CACS were similar to the group with perfusion defects and MDCT with calcium. In the group with known CAD there was association between DM, extent of coronary disease and CACS. There were no associations between the results of SPECT and MDCT and other variables. In the subgroup of 128 patients with follow-up, the average time was 824.5 days (SD 385.9), there were 2 deaths (1.6%) confirmed, however none of cardiovascular cause. Coronary angiography (CATH) (21.1%) was the most frequent event, followed by percutaneous angioplasty (PTCA) (9.4%). Surgical revascularizations were much less frequent (3.1%). There was no myocardial infarction (MI). Similarly, there were no markers of long term prognosis in this sample. Conclusions: Although CAC was as frequent as normal perfusion in SPECT, less than half with normal SPECT may have calcium on MDCT. This results combination (normal SPECT and calcium) had association with dyslipidemia. Also, DM, CACS >400 and percentile equal or above 75% were associate with abnormal SPECT and calcium on MDCT. MDCT combined to SPECT was able to detect ischemia in patients with known coronary stenosis, but there were no associations between the degree of stenosis, or the presence or absence of ischemia and its extent with the combined results. There was a low event rate in the follow-up subgroup.