15283-B-Blokker

101 Accuracy of MIA for the detection of ischemic heart disease 6 INTRODUCTION According to the world health organization cardiovascular disease and stroke are the foremost contributors to worldwide mortality, with ischemic heart disease globally causing almost 9 million deaths per year in 2015. 144 Accurate mortality statistics are important for both policy- and decision-making regarding healthcare funding. For reliable statistics it is essential to perform autopsies in a sufficient proportion of deaths, both in and out of hospital. Despite available modern diagnostic tests, the conventional autopsy still reveals unexpected findings related to the cause of death in 8.4-24.4% and findings that would have affected patient outcome (class I errors) in 4.1-6.7% of cases. 13,22,145 Unfortunately today’s autopsy rate has dropped to alarmingly low percentages worldwide (0-15%), both for academic and nonacademic hospitals. 146 In the late nineties, the imaging autopsy was introduced as alternative to conventional autopsy as a stimulus to postmortem diagnostics. Since then, a growing number of studies have evaluated the diagnostic value of postmortemCT andMRI with or without image guided biopsies. Two review articles concluded that the imaging autopsy, using a non-invasive or minimally invasive approach, can potentially serve as an alternative to conventional autopsy, but more extensive research in different settings is needed to validate these new autopsy methods. 147,148 Imaging protocols designed for the living patient differ from postmortem imaging protocols, in particular for cardiac imaging. For example, wall movement abnormalities of the heart cannot be diagnosed. In living patients, contrast-enhanced imaging, either noninvasive or invasive, is the gold standard for diagnosing ischemic heart disease. Postmortem angiographic studies are feasible and not new; since the discovery of X-rays, angiography of organs and tissues has been used as an adjunct to the autopsy procedure. 149 More recently, postmortem total-body angiography, using CT (CTA) or MRI (MRA), has become technically feasible and there is a growing number of studies investigating its diagnostic value. Preliminary results are promising, especially for establishing ischemic heart disease as the cause of death. 150-152 Interestingly postmortem MRI without the use of contrast agents also shows a sufficient accuracy for detecting both acute and chronic myocardial infarction (MI). The presence and age of MI can be diagnosed by evaluating the signal changes related to morphological alterations in the infarcted myocardium, such as the presence of myocardial edema, fibrosis or fat. 153-156 . Nonenhanced cardiac CT is also useful for detecting coronary artery calcifications.