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News: Congress

EAS2019 Joint ESC/EAS Session: How can we improve imaging strategies for detecting atherosclerosis?

Wednesday 29 May 2019   (0 Comments)
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Experts from the EAS and European Society of Cardiology (ESC) joined forces to address this challenge on Monday. In a thought-provoking presentation,  Professor Valentin Fuster (Mount Sinai Heart, New York, USA) emphasised that targeting intervention to individuals with either subclinical or clinical cardiovascular disease is already too late. Instead, strategies should be directed to promoting cardiovascular health, which would undoubtedly benefit both the individual and society as a whole.1 Given that atherosclerosis is a chronic inflammatory disease, noninvasive imaging approaches aimed at detecting early arterial inflammation have value. Indeed, in a recent report from the PESA (Progression of Early Subclinical Atherosclerosis) study,2 hybrid 18F-fluorodeoxyglucose (18F-FDG) positron emission tomography/magnetic resonance imaging (PET/MRI) was able to detect vascular inflammation in individuals with subclinical atherosclerosis, with 18F-FDG arterial uptake increased with an increasing number of cardiovascular risk factors. Importantly, most of this uptake were detected in plaque-free arterial segments.

Moreover, integrative approaches that combine imaging with genomic screening in early life,3 as well as detection of carriers of mutations predisposing to clonal haematopoiesis that were associated with increased risk for coronary artery disease and coronary-artery calcification,4 will undoubtedly provide added value in directing strategies aimed at cardiovascular health. Added to this, an improved characterization of cells within the atherosclerotic plaques such as macrophages need to be incorporated within system approaches for cardiovascular health. Promotion of cardiovascular health also benefits long-term cognitive function; potentially preventable vascular disease has been shown to have favourable downstream benefit in terms of dementia risk.5 

Ultimately, successful primordial prevention means targeting children, changing the mindset of children with strategies aimed at heart health. An example of such an approach is the Harlem Family Study, which involves both noninvasive imaging and molecular genetic approaches at the point of care to evaluate the benefit of a primordial preventive strategy on longer-term vascular health.

In a subsequent presentation, ESC President Professor Jeroen Bax (University of Leiden, the Netherlands) discussed whether clinicians should use computed tomographic imaging or just simply treat individuals at intermediate or high risk of cardiovascular disease.  In support, findings from the SCOT-HEART trial showed that coronary computed tomographic angiography (CTA) improved diagnostic certainty in the assessment of patients with stable chest pain, although this did not translate to reduction in invasive procedures at 5 years.6 While diagnostic value may be limited by the diffuse nature of atherosclerosis, in stable patients with suspected coronary artery disease, coronary CTA was shown to be an accurate means to guide decisions for invasive coronary angiography.7

In concluding remarks, Professor Bax took a glimpse into the future in considering the use of machine learning in cardiac CT, an evolving field which aims to take account of the multidimensional nature of clinical disease in patients. Future application offers the potential for improved accuracy and precision in addressing uncertainty in the use of invasive procedures.

Professor Erik Stroes (Amsterdam Medical Center, University of Amsterdam, the Netherlands) discussed whether imaging inflammation was relevant for clinical practice, given multilevel inflammatory involvement in atherosclerotic disease. However, he presented clear evidence that inflammatory imaging was feasible and offered predictive value in patients with cardiovascular disease, although validation in large scale prospective studies is still needed. The use of inflammatory imaging can also offer important insights into residual inflammatory activity. Currently, clinical medicine fails to take account of residual inflammatory risk in patients with cardiovascular disease, contributing to up to one-third of the total residual cardiovascular risk in high risk patients.8 In the era of personalised medicine, imaging inflammation offers added value, but  has a number of unresolved uncertainties, relating to cost, discrimination and standardisation, as well as prospective validation in large-scale studies, that will help in defining where these novel imaging approaches can be best applied..

Concluding the session, Professor Stephen Nicholls (Monash University, Australia) discussed issues relating to imaging the vulnerable plaque. There is undoubtedly a clear rationale for doing so, not only to better understand disease biology, but to translate this information to improving diagnosis, risk prediction and evaluation of treatment response. Molecular imaging provides multiple imaging techniques to identify characteristics of vulnerable plaque, incorporating key information related to plaque burden, high-risk plaque characteristics, and disease activity. However, considerable technical challenges remain in delivery. Much of the attention has focused on plaques at risk of rupture, neglecting plaque erosion, which differ in content of lipid, proteoglycan, inflammatory cells, and secondary neutrophil involvement, amongst other characteristics. Ultimately, the question is whether these imaging modalities have a role in evaluation of residual risk, or whether the use of existing therapies have raised the bar so that it is no longer possible to define incremental benefit.

Concluding the session, Professor Bax commented that noninvasive imaging has value in detection of atherosclerosis, and in the primordial setting can help in promotion of cardiovascular health, a more valuable approach from both individual and societal perspectives. Novel imaging approaches targeting inflammation or characteristics of the vulnerable plaque offer additional information, but currently have practical and predictive limitations. Finally, integrative machine learning has potential to resolve these limitations and is likely to become the norm in the future.


1. Fuster V, Frazer J, Snair M, et al. The future role of the United States in global health: emphasis on cardiovascular disease. J Am Coll Cardiol 2107;70:3140-56.

2. Fernández-Friera L, Fuster V, López-Melgar B et al. Vascular Inflammation in Subclinical Atherosclerosis Detected by Hybrid PET/MRI. J Am Coll Cardiol 2019;73:1371-82.

3. Inouye M, Abraham G, Nelson CP et al. Genomic risk prediction of coronary artery disease in 480,000 adults: implications for primary prevention. J Am Coll Cardiol 2018;72:1883-93.

4. Jaiswal S, Natarajan P, Silver AJ et al. Clonal hematopoiesis and risk of atherosclerotic cardiovascular disease. N Engl J Med 2017;377:111-21.

5. Azarpazhooh MR, Avan A, Cipriano LE et al. Concomitant vascular and neurodegenerative pathologies double the risk of dementia. Alzheimers Dement 2018;14:148-56.

6. The SCOT-HEART Investigators. Coronary CT angiography and 5-year risk of myocardial infarction. N Engl J Med 2018;379:924-33.

7. Chang HJ, Lin FY, Gebow D, et al. Selective Referral Using CCTA Versus Direct Referral for Individuals Referred to Invasive Coronary Angiography for Suspected CAD: A Randomized, Controlled, Open-Label Trial. JACC Cardiovasc Imaging 2018 Dec 6. pii: S1936-878X(18)30921-5.

8. Ridker PM. How common is residual inflammatory risk? Circ Re. 2017;120:617-9.

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