Abstract
Despite recent advances, cardiovascular disease remains the leading cause of death globally. As such, there is a need to optimise our current diagnostic and risk stratification pathways in order to better deliver individualised preventative therapies. Non-invasive imaging of coronary artery plaque can interrogate multiple aspects of coronary atherosclerotic disease, including plaque morphology, anatomy and flow. More recently, disease activity is being assessed to provide mechanistic insights into in vivo atherosclerosis biology. Molecular imaging using positron emission tomography is unique in this field, with the potential to identify specific biological processes using either bespoke or re-purposed radiotracers. This review provides an overview of non-invasive vulnerable plaque detection and molecular imaging of coronary atherosclerosis.
Highlights
Despite recent improvements in the identification of coronary artery disease, fatal myocardial infarction remains the leading cause of death globally
We focus on the roles of CT coronary angiography (CTCA) and combined positron emission tomography and CT (PET-CT) in the assessment of vulnerable plaque and coronary artery disease activity
At 5 years, a pre-s pecified secondary analysis demonstrated a reduction in the combined endpoint of coronary heart disease death or non-fatal myocardial infarction in the CTCA arm [2.3% vs 3.9%, hazard ration (HR) 0.59, 95% confidence interval (CI) 0.41–0.84], principally driven by a reduction in non-fatal myocardial infarction (2.1% vs 3.5%, HR 0.60, 95% CI 0.41–0.87).[13]
Summary
Despite recent improvements in the identification of coronary artery disease, fatal myocardial infarction remains the leading cause of death globally. On the basis of currently available data, the use of CTCA in patients with suspected stable angina is recommended as an appropriate first-line investigation in the 2019 European Society of Cardiology chronic coronary syndromes guidelines.[15] the role of CTCA in screening asymptomatic patients for primary prevention is not supported at present[16] and given that CTCA requires the use of ionising radiation and iodinated contrast, this should not be undertaken routinely outside the context of a clinical trial This question will be addressed in the upcoming CTCA for the Prevention of Myocardial Infarction (SCOT-HEART2) randomised controlled trial (NCT03920176). Due to the small size of the coronary arteries and constant motion of the heart throughout the cardiac cycle, there has been significant technical investment in optimising acquisition protocols,[27,28,29] reconstruction algorithms[30] and post-processing interpretation of coronary artery
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