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EAS 2018 report from Advanced Clinical seminar on imaging

Wednesday 9 May 2018   (0 Comments)
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What is meant by significant atherosclerosis in imaging studies?

Both Presidents of the European Society of Cardiology, Professor Jeroen J. Bax (Leiden, The Netherlands) and EAS, Professor Lale Tokgozoglu (Ankara, Turkey) discussed this question in an exciting Advanced Clinical Seminar Monday.

Advances in imaging technology has led to a range of diagnostic tools to characterize high-risk plaque. Yet what is not yet clear from imaging studies is what is meant by ‘significant atherosclerosis’. What can the experts offer to define this terminology?

Professor Bax focused on high risk markers including cardiac computed tomography (CT), which is well established with high diagnostic accuracy for detection of coronary atherosclerosis and stenosis.1 Multislice CT (MSCT) has been shown to have high prognostic accuracy, especially in individuals with high risk coronary artery disease,2 but a positive MSCT does not define the best approach for patient management. Moreover, information from MSCT may differ in the intermediate risk setting. 

There are also unresolved questions as to the value of information relating to the extent, location, severity and composition of plaque.  Currently, plaque stenosis is quantified by visual analysis using MSCT, but a more quantitative approach using QAngioCT which measures both the extent and haemodynamic significance of stenosis may be preferable. The integration of anatomical and functional imaging, such as SPECT-CT, PET-CT, FFRCT or perfusion CT, is clearly a step in the right direction to improve what is meant by ‘significant’ atherosclerosis.3 Finally, imaging needs to be able to differentiate non-calcified high-risk lesions.

Professor Tokgozoglu focused on multimodality imaging as the way to address this uncertainty. BIOIMAGE and PESA studies have shown that risk prediction increases significantly when different vascular beds are imaged with a combination of ultrasound and calcium scoring. Combining PET imaging with CT or MRI allows integrated assessment of plaque composition and activation. Approaches which combine for example, OCT or NIR and intravascular imaging, or the combination of NIR and OCT, has been shown to be superior for assessment of plaque morphology and burden than either technique alone.4 Currently, dual catheters are being developed with miniaturization and the first clinical studies are now in progress. There is, however, a ‘downside’ to this approach. Although shown to have high sensitivity in acute events, the prospective predictive value is low.5 More recently, investigation of a different combination of techniques has shown that in adults without known cardiovascular disease, a multimodality testing strategy using left ventricular hypertrophy by ECG, coronary artery calcium, N-terminal pro B-type natriuretic peptide, high-sensitivity cardiac troponin T, and high-sensitivity C-reactive protein significantly improved global risk assessment.6 

According to Professor Tokgozoglu, multimodality imaging may be the future only if we can define the optimal combination of imaging for each patient and can do this in a cost-effective way minimizing radiation risk to the patient. However, data from prospective randomized controlled trials is still needed.

But all of these considerations may be obsolete in the future with the advent of tailored prevention based on improved risk scores, incorporating genetics, biomarkers and imaging. Indeed, a recent study has highlighted the future for ‘deep learning’ for prediction of cardiovascular risk from retinal fundoscopy imaging.  Multimodality imaging may, however, still have value in improving risk prediction in the setting of extreme risk. All of these approaches are entirely consistent with tailored ‘precision medicine’ approach.


1. Mowatt G, Cook JA, Hillis GS et al. 64-Slice computed tomography angiography in the diagnosis and assessment of coronary artery disease: systematic review and meta-analysis. Heart 2008; 94(11):1386-93.

2. Cheng VY, Berman DS, Rozanski S et al. Performance of the traditional age, sex, and angina typicality-based approach for estimating pretest probability of angiographically significant coronary artery disease in patients undergoing coronary computed tomographic angiography: results from the multinational coronary CT angiography evaluation for clinical outcomes: an international multicenter registry (CONFIRM). Circulation 2011;124:2423-32.

3. Douglas PS, De Bruyne B, Pontone G et al.  1-Year Outcomes of FFRCT-Guided Care in Patients With Suspected Coronary Disease: The PLATFORM Study. J Am Coll Cardiol 2016;68:435-445.

4. Michail M, Serruys PW, Stettler R et al. Intravascular multimodality imaging: feasibility and role in the evaluation of coronary plaque pathology. Eur Heart J - Cardiovascular Imaging 2017;18:613–620.

5. Cheng JM, Garcia-Garcia HM, de Boer SP et al. In vivo detection of high-risk coronary plaques by radiofrequency intravascular ultrasound and cardiovascular outcome: results of the ATHEROREMO-IVUS study. Eur Heart J 2014;35: 639-47.

6. de Lemos JA, Ayers CR, Levine BD et al. Multimodality Strategy for Cardiovascular Risk Assessment: Performance in 2 Population-Based Cohorts. Circulation 2017;135:2119-2132.

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