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Advanced imaging looks set to replace invasive coronary angiography in CAD diagnosis

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Advanced imaging looks set to replace invasive coronary angiography in CAD diagnosis

Saturday, March 3 (ECR) – Imaging has greatly improved the outcome for patients suffering from coronary artery disease (CAD), one of the most common and lethal conditions worldwide.

CT has become central in the diagnosis and characterisation of CAD. Radiologists are already able to predict the prognosis of patients. Also, as technological improvements continue to increase sensitivity and specificity, it is hard not to expect CT to supplant invasive coronary angiography in the future, experts will argue in today’s dedicated Special Focus Session.

In the UK, the recent publication of the National Institute of Clinical Excellence (NICE) guidelines on treating patients with chest pain shows the prominent role played by imaging modalities.

“This is very interesting because, for the first time, it incorporates imaging tests into the patient diagnostic pathway. Previously in mainstream cardiology, most of the tests that were carried out were clinical examinations of the patient’s history, followed by an exercise test, then maybe coronary angiography,” said session chairman Prof. Michael Rees from the Betsi Cadwalladr University Health Board Wales, UK.

An increasing number of imaging modalities are available for the investigation of high-, medium- and low-risk patients, sparing many of them a coronary angiogram; an invasive procedure with an associated morbidity risk.

In lower-risk patients with chest pain, the first test now carried out is a calcium score, to predict risk and determine what the next step should be. A calcium score is a CT examination to check for the build-up of calcium in plaque within coronary arteries.

“It represents a big change in the way we investigate patients,” Rees said. The research going on in Europe should also soon start incorporating all of the clinical research evidence on imaging, he added.

If the calcium score is high, the patient will then go on to have either a coronary CT angiogram (CCTA) or a basic coronary angiogram. If the calcium score is low, the patient may then go on to have CCTA or other tests, or be treated with medication.

CCTA has become vital to the management of CAD patients, thanks to recent technological improvements and the modality’s wide availability around the world.

“All the major questions about the diagnostic power of this modality were answered in the last few years,” said Dr. Filippo Cademartiri, Head of Cardiovascular Imaging at Giovanni XXIII Hospital of Monastier di Treviso, Italy, and a speaker at the session.

With the information collected during the diagnostic process, radiologists can now tell whether patients will develop a cardiovascular event or not, and if yes, which one.

Early studies suggested a potential for prognostic risk assessment through CCTA findings, but were limited by small patient cohorts and a lack of centres. Dr. Cademartiri will present the results of the recent multicentre CONFIRM registry, which was performed on 27,125 patients in Asia, Europe and North America; this large-scale study should add important insights into CCTA findings, he believes.

Significant advances have been made in MR as well; it is increasingly used to determine whether a patient has enough viable myocardium to justify intervention or not. Stress MRI scans and late contrast-enhanced scans are becoming much more common as tests for medium-risk patients. If evidence of cardiovascular disease is found, these patients might then go on to have coronary angiography.

This procedure is likely to lose even more ground to less invasive imaging modalities for the diagnosis and characterisation of CAD in the future.

“I would foresee a point in time when the only reason we would perform coronary arteriography is to carry out therapy or when it is absolutely necessary,” Rees said.

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The European Congress of Radiology is the annual meeting of the European Society of Radiology (ESR), the fastest growing medical society in the world, currently with 56,378 members. The congress, which this year takes place March 1 to 5, at the Austria Center Vienna, annually attracts more than 20,000 delegates from over 90 countries, and the accompanying technical exhibition hosts around 300 international exhibitors across 26,000 m².

Saturday, March 3, 08:30–10:00, Room F2
SF 8b: Cardiac imaging: from diagnosis to prognosis

• Chairman’s introduction
M.R. Rees; Gwynedd/UK
• Coronary calcium scoring: is it good for prognosis assessment?
R. Vliegenthart; Groningen/NL
• Coronary CT angiography to predict future events
F. Cademartiri; Monastier di Treviso/IT
• MRI predictors in coronary artery disease
J. Bogaert; Leuven/BE
• Panel discussion: Cardiac CT and MRI vs traditional prognostic predictors: what is the evidence?

Cardiac Imaging Figure 1 (c) Filippo Cademartiri

Cardiac Imaging Figure 2 (c) Filippo Cademartiri

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