Cauda equina syndrome complicating ankylosing spondylitis: Role of computed tomography and magnetic resonance imaging

Summary We present two cases of cauda equina syndrome in ankylosing spondylitis. Cauda equina syndrome is a rare complication of ankylosing spondylitis, the pathogenesis of which is not well understood. The onset is insidious with pain and sensory symptoms; sphincter disturbances are common. After a period of increasing neurological symptoms, the condition tends to stabilize. The degree of nerve involvement is variable and can be accurately defined by electromyography. The diagnosis has to be confirmed by computed tomography (CT) or magnetic resonance imaging (MRI); myelography must be avoided. There is no specific treatment, except for pain control.The different clinical presentations and the role of new imaging techniques, CT and MRI, are demonstrated.     

基质金属蛋白酶-3与强直性脊柱炎疾病活动相关性研究

目的本试验拟通过检测强直性脊柱炎(AS)患者血清和关节液中基质金属蛋白酶(MMP)-3的表达水平及分析其与AS病人疾病活动的相关性来确证和探讨MMP-3在AS发病中的作用。方法应用酶联免疫吸附试验(ELISA)检测两组AS患者血清中MMP-3的表达水平,一组是41例未用任何抗肿瘤坏死因子(TNF)-琢等生物制剂治疗的AS患者血清,另一组是13例应用抗TNF-琢单克隆抗体Infliximab治疗前和治疗14周后的AS患者血清,同时对比检测了28名正常对照个体血清和8例AS患者关节液中MMP-3的水平。结果AS患者关节液中MMP-3水平显著高于AS患者外周血水平(P<0.00001);41例未用任何生物制剂治疗的AS患者,其血清MMP-3的水平与AS疾病活动指数(BASDAI)(r=0.48,P=0.0007)和血沉(ESR)(r=0.54,P=0.0001)具有明显相关性;同时应用对数相关分析发现根据BASDAI值判别的病情活动度与ESR(P=0.025)和MMP-3(P=0.04)水平之间亦具有高度相关性。应用Infliximab治疗14周后,AS患者血清MMP-3水平和BASDAI值比治疗前显著下降(P=0.013和P=0.00007)。结论AS患者血清中MMP-3水平可作为评价AS疾病活动性潜在的生物学标志物。此外,由于MMP-3在关节和外周血中均有稳定水平的表达,因此MMP-3还是研究AS发病机制的肯定和有用候选基因。     

Magnetic resonance imaging in ankylosing spondylitis

PURPOSE OF REVIEW: The past 18 months has seen considerable advances in the use of MRI for assessment of ankylosing spondylitis, to quantify active inflammation in the spine and sacroiliac joints which may not otherwise be detectable and to therefore measure change due to therapeutic interventions. RECENT FINDINGS: Characterization of the extension and morphology of inflammation in ankylosing spondylitis is now possible with MRI techniques. A number of randomized controlled trials of anti-tumour necrosis factor agents in ankylosing spondylitis have now been published showing regression of inflammatory lesions in the spine by MRI. Furthermore, the role of MRI for the early diagnosis of spondyloarthritis has become clearer. This review discusses the techniques used, the capabilities and the shortcomings of MRI in assessing ankylosing spondylitis patients. SUMMARY: MRI techniques have implications for early identification and intervention in patients with ankylosing spondylitis.     

Spinal inflammation by magnetic resonance imaging in patients with ankylosing spondylitis: association with disease activity and outcome parameters

Magnetic resonance imaging (MRI) has major contribution in early diagnosis of ankylosing spondylitis (AS). As it is difficult to determine disease activity owing to the lack of close relation between laboratory tests, clinical findings and imaging, MRI has been used as an objective outcome measure. The aim of this study is to investigate the relation between spinal MRI findings with disease activity and other outcome measures. Fifty patients fulfilling modified New York criteria for AS were enrolled to the study. All the patients were evaluated with Bath AS Disease Activity Index (BASDAI), AS Disease Activity Score (ASDAS), Bath AS Functional Index (BASFI), Bath AS Metrology Index (BASMI), Bath AS Radiology Index (BASRI) and As Quality of Life. Erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) were measured as laboratory parameters, and ASspiMR scores were determined by spinal MRI. The median total ASspiMR-a score was 5.2. Spinal inflammation was evaluated in spinal segments, and thoracic segments had the highest mean ASspiMR-a level (3.1?±?5.94). Cervical and lumbar ASspiMR were correlated with only BASRI, and total ASspiMR score was correlated with BASRI, BASMI and CRP. Thoracic ASspiMR score was correlated with patient??s and doctor??s global assessments, BASFI, BASMI, BASRI, ASDAS A, ASDAS B, ASDAS C, ASDAS D, ESR and CRP (P?<?0.05). According to our results, the thoracic spine was the most related region with disease activity parameters and clinical outcome measures, so we suggest thoracic spine MRI evaluation in order to determine the disease activity.     

Value of diffusion-weighted magnetic resonance imaging in early diagnosis of ankylosing spondylitis

The objective of this study is to estimate the value of diffusion-weighted MRI (DWI) in the detection of abnormalities in sacroiliac joints in the patients with early ankylosing spondylitis (AS) and investigate the feasibility of whole-body DWI (WB-DWI) in systemic evaluation of AS. Sixteen patients with early AS, 18 patients with simple low back pain (LBP), and 18 healthy volunteers were involved in this study. All subjects underwent conventional MRI and DWI. Apparent diffusion coefficient (ADC) in subchondral bone marrows of sacroiliac joints was measured. Independent-sample t test was used to statistically analyze the difference of ADC values between groups. WB-DWI was performed in additional 12 patients with clinically confirmed AS. The image results were analyzed by multiple post-processing techniques, as compared to conventional MRI. In AS patients, mean ADC values were (0.494?±?0.170)?×?10^?3?mm²/s in sacrum and (0.513?±?0.129)?×?10^?3?mm²/s in ilium, which were significantly higher than those of LBP ((0.306?±?0.057)?×?10^?3?mm²/s in sacrum and (0.323?±?0.083)?×?10^?3?mm²/s in ilium) and healthy volunteers ((0.315?±?0.009)?×?10^?3?mm²/s in sacrum and (0.319?±?0.012)?×?10^?3?mm²/s in ilium). No statistical differences were found between simple LBP and healthy volunteers. Mean ADC value of multiple lesions in AS was (0.932?±?0.299)?×?10^?3?mm²/s. By WB-DWI, abnormal signals of sacroiliac joints and extra-sacroiliac joint lesions were demonstrated in the locations corresponding with clinical findings. Mean ADC values of multiple lesions were (1.298?±?0.323)?×?10^?3?mm²/s in sacrum and (1.216?±?0.311)?×?10^?3?mm²/s in ilium. DWI and WB-DWI were shown to be effective in differentiation and systemic evaluation of early AS. Both techniques are likely to play an importance role in the early diagnosis of AS and assessment of treatment response.     

Scoring inflammatory activity of the spine by magnetic resonance imaging in ankylosing spondylitis: a multireader experiment

OBJECTIVE: Magnetic resonance imaging (MRI) of the spine is increasingly important in the assessment of inflammatory activity in clinical trials with patients with ankylosing spondylitis (AS). We investigated feasibility, inter-reader reliability, sensitivity to change, and discriminatory ability of 3 different scoring methods for MRI activity and change in activity of the spine in patients with AS. METHODS: Thirty sets of spinal MRI at baseline and after 24 weeks of followup, derived from a randomized clinical trial comparing a tumor necrosis factor (TNF)-blocking drug (n = 20) with placebo (n = 10) and selected to cover a wide range of activity at baseline and change in activity, were presented electronically in a partial latin-square design to 9 experienced readers from different countries (Europe, Canada). Readers scored each set of MRI 3 times, using 3 different methods including the Ankylosing Spondylitis spine Magnetic Resonance Imaging-activity [ASspiMRI-a, grading activity (0-6) per vertebral unit in 23 units]; the Berlin modification of the ASspiMRI-a; and the Spondyloarthritis Research Consortium of Canada (SPARCC) scoring system, which scores the 6 vertebral units considered by the reader as the most abnormal, with additional scores for "depth" and "intensity." Both the order of the methods used by each reader and the timepoints (before/after treatment) were randomized. Feasibility of each scoring system was evaluated by measuring the mean time needed to score each set of MRI, and inter-reader reliability was evaluated by smallest detectable change (SDC) and by intraclass correlation coefficients (ICC) for all readers together and for all possible reader pairs separately. Sensitivity to change was investigated by calculating Guyatt's effect size on change scores. Discriminatory ability was assessed using Z-scores (Mann-Whitney test) comparing change in score between patients treated with TNF-blocking drug and placebo. RESULTS: The mean time to score one set of MRI was shortest for the Berlin method. SDC was lowest for the Berlin method and highest for SPARCC. Overall inter-reader ICC per method were between 0.49 and 0.77 for scoring activity status, and between 0.46 and 0.72 for scoring activity change. ICC for all possible reader pairs showed much more fluctuation per method, with lowest observed values of about 0.05 (very low agreement) and highest observed values over 0.90 (excellent agreement). In general, ICC for SPARCC were consistently higher than for other systems. Sensitivity to change differed per reader, and was more consistent with SPARCC than with the other methods, but was in general excellent for all 3 methods. Discrimination between groups (TNF-blocker vs placebo) assessed by Z-scores was good and comparable among methods. CONCLUSION: This experiment demonstrates the feasibility of multiple-reader MRI scoring exercises for method comparison, provides evidence for the feasibility, reliability, sensitivity to change, and discriminatory capacity of all 3 tested scoring systems to be used in assessing spinal activity on MRI in patients with AS in clinical trials. On the basis of these results it is not possible to prioritize one of the 3 methods.     

Serum matrix metalloproteinases and tissue inhibitors of metalloproteinases in ankylosing spondylitis: MMP-3 is a reproducibly sensitive and specific biomarker of disease activity

OBJECTIVE: To submit serum levels of matrix metalloproteinases (MMPs) and tissue inhibitors of metalloproteinases (TIMPs) to statistical analyses to test their exact degrees of clinical usefulness as biomarkers for detecting high disease activity in ankylosing spondylitis (AS), comparing them with erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP). METHODS: Serum levels of MMP-1, -3, -9 and TIMP-1 and -2 were measured in 42 AS patients and 20 healthy controls. The Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) provided the gold standard for measuring disease activity. Patients with BASDAI > or =4 were regarded as having high disease activity. The results were compared with results for a separate cohort of 41 AS patients. RESULTS: Only MMP-3 levels were significantly higher in AS patients than in healthy controls (P<0.001). Within AS patients, MMP-3 levels were also higher in patients with high disease activity compared with those with low disease activity, and correlated significantly with BASDAI (r = 0.366, P = 0.017) and functional indices (r = 0.344, P = 0.026). The correlation with BASDAI was stable in a 1-yr follow-up (r = 0.464, P = 0.095) and reproducible with two different enzyme-linked immunosorbent assays. For detecting high disease activity, the sensitivity and specificity of MMP-3 level was 69.2 and 68.8% respectively. Most importantly, using receiver operating characteristic plots to analyse the two cohorts, MMP-3 was more accurate than ESR and CRP in detecting AS patients with high disease activity (P = 0.01 and P = 0.009, respectively). CONCLUSION: Using several analytical approaches that have never been reported previously, we showed that MMP-3 is a more useful biomarker than ESR and CRP to detect high disease activity in AS.     

Efficacy of anakinra in active ankylosing spondylitis: a clinical and magnetic resonance imaging study

OBJECTIVE: To determine the efficacy of anakinra, an interleukin 1 receptor antagonist in active ankylosing spondylitis (AS), and to investigate the effect of anakinra treatment on spinal enthesitis/osteitis using magnetic resonance imaging (MRI). METHODS: A 3 month open label study of anakinra (100 mg subcutaneous injection daily) was carried out in nine patients with active AS who had back pain and an increased acute phase response, and who had failed to respond to at least one non-steroidal anti-inflammatory drug. Clinical assessment included the Bath AS Functional Index (BASFI), Bath AS Disease Activity Index (BASDAI), and AS Quality of Life (ASQoL) before and after treatment. Fat suppressed MRI of the spine and sacroiliac joints was performed with a 1.5 T scanner at baseline and at 3 months to determine the effect of treatment on spinal enthesitis/osteitis. RESULTS: Significant improvement was found in the BASFI (median baseline 5.88, 3 months 3.63, p = 0.021), BASDAI (median baseline 5.63, 3 months 3.48, p = 0.028), ASQoL (median baseline 12, 3 months 8, p = 0.011) and laboratory measures reflecting inflammation, with C reactive protein (median baseline 31 mg/l, 3 months 17 mg/l, p = 0.036) and erythrocyte sedimentation rate (median baseline 19 mm/1st h, 3 months 15 mm/1st h, p = 0.008) also showing significant improvement. Six patients (67%) achieved the Assessments in AS (ASAS) Working Group criteria of 20% improvement. Of the 38 regions of enthesitis/osteitis determined by MRI at baseline, 23 (61%) either improved or regressed completely. CONCLUSIONS: This open label pilot study suggests that anakinra is effective in controlling the clinical manifestations of AS. The clinical response was reflected by an improvement in MRI determined spinal enthesitis/osteitis.     

Discovertebral lesion in ankylosing spondylitis: differential diagnosis with discitis by magnetic resonance imaging

 Ankylosing spondylitis (AS) is occasionally accompanied by erosive changes in the vertebral endplate at one or more restricted levels (Andersson lesions). The radiographic findings of this lesion are similar to those of bacterial discitis, and a differential diagnosis between them is often difficult. These diseases must be diagnosed correctly because they require different treatments. In order to evaluate the prevalence of Andersson lesions in the Japanese population, we examined 31 cases of AS which were treated in our department, and Andersson lesions were found in three (9.7%) of them. All these three cases developed Andersson lesions in the earlier phase of the AS, and differentiating the lesions from bacterial discitis was difficult. The details of these three cases are reviewed, and the importance of differentiating between Andersson lesions and bacterial discitis is discussed. Plain radiographs showed no clear difference between these conditions, but magnetic resonance imaging (MRI) was found to be more efficient. Received: February 5, 2001 / Accepted: September 27, 2001     

强直性脊柱炎新的疾病活动性指数在中国患者中的应用价值研究

目的 验证新的强直性脊柱炎(AS)疾病活动性指数(ASDAS)在中国的AS患者中的辨别能力,评估其临床应用价值.方法 本研究共纳入AS患者129例,分别为参加依那西普临床试验的活动期AS患者(87例)和使用类克治疗的AS患者(42例).分别以4个ASDAS、毕氏AS疾病活动指数(BASDA1)及患者总体评价来评价患者的疾病活动性水平和治疗效果.计算标准化的均数差(SMD)分析指标的辨别能力,运用Pearson相关分析.两独立样本t检验与一元线性回归进行统计学处理.结果 无论是基线水平还是治疗6周后的变化程度,4个新的ASDAS均与患者总体评价(r=0.56～0.74)、红细胞沉降率(ESR)(r=0.50～0.80)及C反应蛋白(CRP)(r=0.50～0.69)有较好的相关性.4个ASDAS对AS患者的疾病活动性水平及治疗前后病情变化程度的辨别能力均优于BASDA1、患者总体评价、ESR和CRP.4个ASDAS之间差异无统计学意义.结论 新的ASDAS用于评价我国AS患者的疾病活动性和药物疗效有较高的辨别能力,值得临床推广和应用.     

Andersson lesions of whole spine magnetic resonance imaging compared with plain radiography in ankylosing spondylitis

The objective of this study was to identify the characteristics of Andersson lesions using whole spine magnetic resonance imaging (MRI) compared with plain radiography in ankylosing spondylitis (AS). A total of 62 patients with AS who had undergone whole spine MRI and plain radiography were retrospectively enrolled in this study. We compared the number of discovertebral units (DVUs) with Andersson lesions with clinical and radiographic indices such as erythrocyte sediment rate (ESR), C-reactive protein (CRP), the Bath Ankylosing Spondylitis Disease Activity Index (BASDAI), the Bath Ankylosing Spondylitis Functional Index (BASFI), and modified Stoke Ankylosing Spondylitis Spine Score (mSASSS). Fifty-three patients (85.5 %) by whole spine MRI and 23 patients (37.1 %) by plain radiography had at least one Andersson lesion. We found 129 DVUs with Andersson lesions (11.1 %) by MRI and 35 DVUs by plain radiography over all the spine levels. Andersson lesions by MRI were most commonly detected at the lower thoracic spine (from T7-8 to T12-L1). Among the 151 total Andersson lesions by whole spine MRI, 41 were identified as central disc type, 26 as anterior peripheral disc type, 44 as posterior peripheral disc type, and 40 as diffuse disc type. However, the number of Andersson lesions did not correlate with ESR, CRP, BASDAI, BASFI, or mSASSS (p > 0.05 for all). Our study indicates that the presence of Andersson lesions in patients with AS is clearly underestimated. MRI is a superior technique for detecting early Andersson lesions compared with plain radiography.     

Comparison of the BASDAI and the miniBASDAI in assessing disease activity in patients with ankylosing spondylitis

The BASDAI (Bath Ankylosing Spondylitis Disease Activity Index) is the most widely used instrument for the assessment of disease activity in ankylosing spondylitis (AS). Objective. The aims to investigate whether the alternative BASDAI, here termed as the miniBASDAI [(Question (Q) 1 fatigue + Q2 spinal pain) + mean of (Q5 strength morning stiffness + Q6 duration morning stiffness)] / 3], measures disease activity more accurately in the subgroup of AS patients without peripheral manifestations. One hundred and ten patients were included in this cross-sectional study according to the modified New York criteria for AS. Clinical and biological parameters were evaluated. The disease activity was evaluated by the BASDAI. We calculated the miniBASDAI by omitting both the peripheral joints and the enthesitis questions: questions 3 and 4. Patients were dichotomized into a “P+” group if peripheral manifestations were present (at least arthritis or enthesitis) and a “P−” group, the subgroup without peripheral involvement (with either arthritis or enthesitis). Correlation of the BASDAI and miniBASDAI with other disease parameters were examined with the Spearman's rank correlation analysis. One hundred and ten patients were recruited. The percentage of patients with pure axial disease manifestation without peripheral involvement “P − group” was 42.7%. We found a similarly good correlation of the miniBASDAI with patient global, physician on disease activity, BASFI, ESR and CRP if compared to the correlation of the original BASDAI with these disease parameters, also in the group without peripheral involvement. Our study suggests that the BASDAI remains valid in assessing disease activity in AS patients with and without peripheral manifestations.     

Serum levels of matrix metalloproteinase 3 and macrophage colony-stimulating factor 1 correlate with disease activity in ankylosing spondylitis

OBJECTIVE: To assess the usefulness of measuring serum matrix metalloproteinase 3 (MMP-3) and macrophage colony-stimulating factor (M-CSF) in patients with ankylosing spondylitis (AS). METHODS: Serum levels of MMP-3 and M-CSF were measured in AS patients who did and did not receive infliximab treatment. These were compared with those of 28 healthy subjects. RESULTS: In the group of AS patients not treated with biologics, both M-CSF and MMP-3 correlated with the Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) values, but not with each other. Logistic regression analysis showed that MMP-3 values were high in those with severely active disease. Infusions of infliximab in AS patients led to a significant decrease in the values of the BASDAI as well as the serum MMP-3, but no change in the serum M-CSF values. CONCLUSION: MMP-3 and M-CSF are potentially useful markers of AS disease activity.     

The functional significance of sacroiliitis and ankylosing spondylitis in Reiter's syndrome

The frequent development of sacroiliitis and ankylosing spondylitis (AS) in patients suffering from Reiter's Syndrome (RS) has been stressed by a number of authors. This study was designed to ascertain the frequency of these problems in our RS patients, whether they were related to other clinical features of RS and what was the extent of the resulting disability. Fifty-five patients (50 men and 5 women) with RS with a mean duration of 9.3 years were assessed radiologically to determine the prevalence of sacroiliitis and thoracolumbar syndesmophyte formation. These radiological findings were correlated with HLA-B27, clinical features and functional status. Sacroiliitis was found in 22 patients (40%) but was mild in severity, frequently asymmetrical and very rarely associated with syndesmophyte formation. Sacroiliitis occurred significantly more commonly in patients with iritis and/or a prolonged disease duration (p less than 0.05) but although it was also found more frequently in HLA-B27 positive patients this was not significant (0.1 greater than p greater than 0.05). Some restriction in back movement was observed in 31 patients (56.3%) but only two patients satisfied New York criteria for AS and just one was functionally impaired by his back disease. Although the frequent finding of sacroiliitis in RS may provide an interesting insight into the interrelationship between RS and AS, our study shows that this sacroiliitis is commonly asymptomatic and does not provide a problem in management.     

Spondyloarthritis Research Consortium of Canada magnetic resonance imaging index for assessment of spinal inflammation in ankylosing spondylitis

OBJECTIVE: To develop a feasible magnetic resonance imaging (MRI)-based scoring system for spinal inflammation in patients with spondylarthropathy that requires minimal scan time, does not require contrast enhancement, evaluates the extent of lesions in 3 dimensional planes, and limits the number of vertebral levels that are scored because MRI demonstrates characteristic inflammatory lesions in the spine of patients with ankylosing spondylitis (AS) prior to the development of typical features on plain radiographic. METHODS: Our scoring method was based entirely on the assessment of increased signal denoting bone marrow edema on T2-weighted STIR sequences. Blinded MRI films were assessed in random order at 2 sites by 3 blinded readers at each of the 2 sites (the Universities of Alberta and Toronto). Intra- and interreader reliability was assessed by intraclass correlation coefficient. The 24-week response of patients with AS randomized to infliximab:placebo (8:3) was assessed by effect size and standardized response mean. RESULTS: An initial analysis of all discovertebral units (DVUs) in the spine of 11 patients demonstrated a mean of 3.2 (95% confidence interval 3.2, 5.2) affected units, while limiting the scoring to a maximum of 6 units captured most of the affected units. We scanned 11 patients with AS with clinically active disease and 20 additional patients randomized to a 24-week trial of either infliximab or placebo. Intraobserver reproducibility for the 6-DVU STIR score ranged from 0.93 to 0.98 (P < 0.0001). Interobserver reproducibility of scores by readers from both sites was 0.79 (P < 0.0001) for status score and 0.82 (P < 0.0001) for change score. Analysis of pretreatment and posttreatment scores for all 20 patients randomized to infliximab/placebo showed a large degree of responsiveness (standardized response mean = 0.87). Reproducibility and responsiveness were only slightly improved by using contrast enhancement with gadolinium diethylenetriaminepentaacetic acid. CONCLUSION: The Spondyloarthritis Research Consortium of Canada MRI index is a feasible, reproducible, and responsive index for measuring spinal inflammation in AS.     

Role of magnetic resonance imaging in the assessment of disease activity in thyroid-associated ophthalmopathy.

Two different phases in disease activity are observed during the clinical course of thyroid-associated ophthalmopathy (TAO). The assessment of disease activity is important for predicting the outcome of medical management because medical treatment can be effective in the active stage. The aim of this study was to investigate whether magnetic resonance imaging (MRI) could assess the disease activity in TAO. To investigate the relation between MRI-T2 signal intensity (SI) and extraocular muscle (EOM) size, 11 patients with TAO were evaluated. EOM sizes (enlargement, volume) were measured by MRI-T1 image. T2-SI of EOM was expressed as a percentage of temporal muscle. The reduction in T2-SI was significantly positively correlated with that of EOM enlargement after treatment. Additionally, T2-SI in pretreatment showed a significant correlation with reduction in EOM volume for therapeutic effect, which indicates T2-SI in pretreatment can be one of the reliable parameters for predicting the therapeutic outcome of treatment. To investigate whether MRI-T2 pattern could predict the reversibility of diplopia, 28 patients with Graves' disease with or without ophthalmopathy were evaluated. Patients with TAO with reversible diplopia showed an uniform T2 pattern in enlarged EOM. However, in patients with irreversible diplopia caused by the mechanical limitation of EOM, MRI-T2 image showed no uniformity with a partial appearance of low T2-SI. The partial low T2-SI may indicate the progress of inactive (fibrotic) change in EOM after active (inflammatory) change. In conclusion, MRI is a useful tool for detection not only of EOM enlargement, but also disease activity in TAO. MRI-T2 SI and pattern can predict the outcome of medical management in TAO.     

Role of cardiac magnetic resonance imaging in ischaemic heart disease

Cardiac magnetic resonance imaging is a new imaging method that has much to offer clinicians caring for patients with ischaemic heart disease. This article describes briefly the basic principles and practical aspects of cardiac magnetic resonance imaging, and summarizes the pathophysiology of ischaemic heart disease. Then it discusses in detail the use of cardiac magnetic resonance imaging for detection of coronary artery disease, and for assessment of acute and stable coronary syndromes.