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Imaging of coronary atherosclerosis — evolution towards new treatment strategies

Key Points

  • Advances in invasive and noninvasive imaging of the coronary arteries have progressed our understanding of the mechanisms underlying the precipitation of acute myocardial infarction, a leading cause of death worldwide

  • Imaging can provide assessments of luminal stenosis, plaque burden, plaque characteristics, disease activity, and ischaemia, generating complementary and potentially synergistic information about coronary atherosclerosis

  • Advances in imaging offer the potential to identify individuals at highest risk of myocardial infarction — the 'vulnerable patient'; these individuals might then be targeted with aggressive therapy to prevent future events

  • The next challenge is to demonstrate that these imaging techniques can have a beneficial and cost-effective effect on cardiovascular outcomes for patients with coronary artery disease

Abstract

Coronary atherosclerosis and the precipitation of acute myocardial infarction are highly complex processes, which makes accurate risk prediction challenging. Rapid developments in invasive and noninvasive imaging technologies now provide us with detailed, exquisite images of the coronary vasculature that allow direct investigation of a wide range of these processes. These modalities include sophisticated assessments of luminal stenoses and myocardial perfusion, complemented by novel measures of the atherosclerotic plaque burden, adverse plaque characteristics, and disease activity. Together, they can provide comprehensive, individualized assessments of coronary atherosclerosis as it occurs in patients. Not only can this information provide important pathological insights, but it can also potentially be used to guide personalized treatment decisions. In this Review, we describe the latest advances in both established and emerging imaging techniques, focusing on the strengths and weakness of each approach. Moreover, we discuss how these technological advances might be translated from attractive images into novel imaging strategies and definite improvements in clinical risk prediction and patient outcomes. This process will not be easy, and the many potential barriers and difficulties are also reviewed.

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Figure 1: Imaging assessments of luminal stenosis, haemodynamic obstruction, and myocardial ischaemia in different patients.
Figure 2: Imaging of atherosclerotic plaque burden.
Figure 3: Imaging of adverse plaque characteristics.
Figure 4: Imaging of atherosclerotic disease activity.
Figure 5: Imaging pathway for the assessment of patients with chest pain.
Figure 6: Possible approach using multimodality imaging to risk stratify patients with atherosclerosis.

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Acknowledgements

We thank Michelle Williams (Centre for Cardiovascular Science, University of Edinburgh, UK) and Charles Taylor (HeartFlow Inc., Redwood, California, USA) for providing images used as part of Fig. 1. M.R.D. and D.E.N. are supported by the British Heart Foundation (SS/CH/ 09/002/26360, FS/13/77/30488, SS/CH/09/002/2636, FS/14/78/31020, CH/09/002). M.R.D. is the recipient of the Sir Jules Thorn Award for Biomedical Research 2015. M.M. is supported by the Dowager Countess Eleanor Peel Trust (Rothwell-Jackson Travelling Fellowship, UK) and the Dickinson Trust Scholarship (UK). P.S. is supported by NIH/NHLBI R01 HL089765. D.D. is supported by research grants from the American Heart Association. D.D. and D.S.B. are supported by research grants from the American Heart Association and Adelson Family Foundation. Z.A.F. is supported by NIH/NHLBI R01 HL071021, NIH/NHLBI R01 HL128056, and NIH/NBIB R01 EB009638. D.E.N. is the recipient of a Wellcome Trust Senior Investigator Award (WT103782AIA).

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M.R.D. and D.B. discussed the content of the article, and M.R.D. and M.K.D. wrote the manuscript. All the authors reviewed/edited the article before submission.

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Correspondence to Marc R. Dweck.

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Cedars-Sinai Medical Center (M.M., P.S., D.D., D.B.) licenses nuclear cardiology software to several instrumentation vendors. P.S. has received grant support from Siemens. D.E.N. is the chief investigator of the PREFFIR study (NCT02278211). The other authors declare no competing interests.

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Dweck, M., Doris, M., Motwani, M. et al. Imaging of coronary atherosclerosis — evolution towards new treatment strategies. Nat Rev Cardiol 13, 533–548 (2016). https://doi.org/10.1038/nrcardio.2016.79

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