Numerous opportunities to improve the diagnosis and management of SIHD remain. Large registries have the potential to improve the diagnosis of IHD and to assess risk according to clinical information and results from noninva- sive testing. Risk-assessment strategies from older databases should be updated with modern information and statistical techniques. Technical development across all cardiac imag- ing modalities continues to evolve rapidly, often outpacing the ability to perform rigorous clinical validation and appli- cation. Current and anticipated technical developments of CT scanners and software are intended to improve the spatial and temporal resolution of cardiac CT images while reducing the radiation dose received from a typical exami- nation. They include wider detector arrays that allow higher numbers of simultaneously acquired image slices, faster x-ray tube rotation times, and the use of alternative image reconstruction techniques that target image noise, all of which could improve the diagnostic value of CCTA in currently challenging scenarios, such as calcified coronary arteries and coronary stents. The improvement also will
foster the study and clinical use of newer applications of cardiac CT, such as coronary plaque characterization, late enhancement imaging for the detection of myocardial scar,
and MPI to detect myocardial ischemia (1252). Efforts
currently under way to obtain perfusion information from
CCTA images are promising (196 –201), with one report
also calculating FFR with CCTA (195). Moreover, plaque
quantification software is in development and could further guide accurate detection of atherosclerotic disease burden (1253).
Several new developments in stress nuclear MPI have occurred, including new radioisotopes: 1) an F18 PET perfusion agent (in Phase III trials), which will allow exercise PET testing;
2)123I-beta-methyl-iodophenylpentadecanoic acid SPECT, with
the unique ability to document metabolic alterations representing prior ischemic episodes (i.e., ischemic memory); and 3) 123I-
labeled meta-iodobenzylguanidine SPECT, which could be helpful for assessment of arrhythmic risk in SIHD patients
(1254). Several new SPECT cameras also have been intro-
duced into the marketplace and offer the opportunity for improved image quality within a substantially shorter time
period and with a lower radiation dose (1255,1256). Several
studies have correlated atherosclerotic plaque characteristics with the extent of ischemic myocardium by stress nuclear
MPI (202–206,215). Finally, the diagnostic and prognostic
value of PET flow reserve data is currently under intense investigation (185,1257).
Echocardiography, being the most portable and widely available stress imaging technique, has developed novel methods that are promising in the assessment of SIHD patient. Speckle-tracking echocardiography provides a 2-dimensional, angle-independent, real-time evaluation of myocardial strain and has been shown to detect myocardial
ischemia incremental to wall motion analysis (1258,1259).
Recent reports of contrast echocardiography MPI during vasodilating stress indicate that it is a potentially robust and
clinically viable tool in detection of CAD (1260). Finally,
3-dimensional techniques can provide an improved assess- ment of cardiac size and function in patients with SIHD.
Increasing recognition of the ability of CMR to accu- rately assess abnormal myocardial physiology of CAD by combined imaging of rest and stress ventricular function, perfusion, and myocardial viability is expected to increase its
use in SIHD (172,1261,1262). With rapid data acquisition
by parallel imaging, real-time cine, or sub-second single- shot imaging methods, a diagnostically adequate CMR can be obtained without the need for patient breath-holding or
ECG gating (1263). A routine CMR assessment of CAD
can be achieved in⬍30 minutes. These developments likely
will improve diagnostic consistency and patient throughput of CMR. CMR myocardial perfusion and LGE imaging for ischemia and scar, respectively, have improved image quality at 3.0T field strength compared to 1.5T and have been shown to improve diagnostic accuracy in detecting CAD
(1264). Whole-heart 3-dimensional coronary magnetic res-
shown promising pilot results and is being evaluated in clinical trials (1265,1266).
Further studies on lipid management are warranted to ascertain the optimal drug regimens for patients with SIHD. Questions remain as to the optimal dose of statins and the effectiveness of combining lipid-lowering medi- cations. In addition, studies that establish the effective- ness of CABG in comparison with contemporary GDMT are necessary, as are studies that better define the relative benefits of different revascularization techniques. (Figure 13).
Presidents and Staff
American College of Cardiology Foundation
William A. Zoghbi, MD, FACC,President
Thomas E. Arend, Jr. Esq, CAE,Interim Chief Staff Officer
William J. Oetgen, MD, MBA, FACC,Senior Vice
President, Science and Quality
Charlene L. May,Senior Director, Science and Clinical Policy
Erin A. Barrett, MPS,Senior Specialist, Science and Clinical
Policy
American College of Cardiology Foundation/American Heart Association
Lisa Bradfield, CAE, Director, Science and Clinical Policy
Maria Koinis,Specialist, Science and Clinical Policy
Sue Keller, BSN, MPH, Senior Specialist, Evidence-Based
Medicine
American Heart Association
Gordon F. Tomaselli, MD, FAHA, President
Nancy Brown,Chief Executive Officer
Rose Marie Robertson, MD, FAHA, Chief Science Officer
Gayle R. Whitman, PhD, RN, FAHA, FAAN,Senior Vice
President, Office of Science Operations
Judy L. Bezanson, DSN, RN, CNS-MS, FAHA, Science
and Medicine Advisor, Office of Science Operations
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