Imagine if we could non-invasively, reliably, and quantitatively detect coronary atherosclerosis and coronary luminal narrowing early in the development of coronary artery disease (CAD). We could fundamentally change the way CAD is diagnosed and treated. Such non-invasive and quantitative imaging of CAD using computed tomography (CT) is increasingly becoming a clinical reality worldwide, based on evidence generated in a multidisciplinary manner. The two key areas in which evidence has accumulated are the high diagnostic accuracy of CT when compared with invasive coronary angiography (ICA) as the reference [1‐5] and improved patient outcomes using CT for comparative effectiveness in clinical trials [6‐8].
This effort required technical developments towards multislice CT and cardiac-phase reconstruction [9, 10], as well as clinical evidence from multicentre registries [11‐13], meta-analyses [1‐5] and randomised controlled trials [6‐8]. Three large multicentre clinical trials in stable chest pain patients with intermediate likelihood of CAD have been published (PROMISE, SCOT-HEART and DISCHARGE) and one large trial is ongoing (CLEAR-CAD). PROMISE indicated that CT is associated with a lower rate of death or non-fatal myocardial infarction compared to functional testing [6]. SCOT-HEART found fewer deaths from CAD or non-fatal myocardial infarction with CT and standard care compared to standard care alone at 5 years of follow-up [7]. DISCHARGE showed fewer major procedure-related complications in the CT compared to the ICA group [8].
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Three fundamental changes
Evidence has been generated primarily through close multidisciplinary collaboration between radiologists, cardiologists, cardiac surgeons, statisticians, epidemiologists, trialists and engineers. However, translating this evidence so that CT can truly begin to build bridges in CAD will require further multidisciplinary clinical collaboration to achieve real clinical impact through improved patient lives and well-being. What are the main arguments for integrating CT into the clinical pathways for patients with stable chest pain and suspected CAD? Based on the evidence described above, three fundamental changes in the approach to CAD are suggested [14] (Table 1).
Table 1
Three fundamental changes in the approach to CAD
Fundamental change | What CT provides | Evidence for change |
|---|---|---|
1. Better prevention of cardiovascular events with the help of non-invasive imaging for the characterisation and quantification of coronary atherosclerosis | Early detection of coronary atherosclerosis by CT may lead to increased use of preventive therapy which results in fewer cardiovascular events | SCOT-HEART: more patients in the CT group used aspirin and statins at 5-year follow-up CAD-Man: higher statin adherence in the CT group at follow-up |
2. Individual determination of treatment strategy becomes possible using non-invasive imaging for determining individually the presence and extend of CAD | Non-invasive assessment of obstructive CAD by CT for individualised decision-making about who may benefit most from revascularisation with additional functional tests | DISCHARGE: 50% greater use of additional invasive or non-invasive functional testing with 25% fewer revascularisation but similar angina reduction at follow-up |
3. Improved procedural planning for the revascularisation strategy in patients with obstructive CAD | CT provides imaging biomarkers that could be used to guide revascularisation planning in individual patients in the future | Early, non-randomised studies; future randomised trials are needed |
First, CT can better detect non-obstructive CAD and therefore early coronary atherosclerosis compared to ICA [8]. This may lead to increased use of preventive therapy with CT. In SCOT-HEART, more patients in the CT group used aspirin (52% vs 41%) and statins (59% vs 50%) at 5-year follow-up compared with the standard care group [15], which was associated with 50% reduction in CAD mortality or non-fatal myocardial infarction [7]. In addition, patients in the CT group of the CAD-Man trial had higher statin adherence (60%) compared with the ICA group (39%), resulting in greater cholesterol reduction at 3.3 years [16]. Better prevention contributes to a long-term reduction in myocardial infarction and stroke and is facilitated by the ability of CT to more accurately identify non-obstructive CAD when compared with ICA (36% versus 22%) [8].
Second, CT is well suited for determining the best treatment strategy in patients with suspected obstructive CAD [14]. The DISCHARGE trial showed a 50% greater use of additional invasive or non-invasive functional testing in the CT group compared with the ICA group, which was associated with a 25% reduction in revascularisation with no difference in angina reduction at 3.5 years of follow-up [8]. Non-invasive assessment of obstructive disease and individualised decision-making about who may benefit most from revascularisation is therefore an important part of the potential future success story of CT in CAD.
Third, improved procedural planning can be achieved in patients with obstructive CAD confirmed by CT. In patients with high-risk anatomy in whom revascularisation provides a prognostic benefit, the route of revascularisation (i.e. percutaneous or surgical or both) could in the future be determined based on quantitative coronary artery imaging biomarkers generated from CT [17‐23]. It is just a matter of time before coronary artery bypass graft surgery can be planned based on CT, provided the image quality is high and taking into account additional functional testing and accepted severity (SYNTAX) criteria. For instance, an initial study showed that heart team decisions based on CT for the route of revascularisation were in high agreement when compared with ICA [24]. Furthermore, an ongoing nonrandomised study analyses the safety and feasibility of CT guidance for planning and executing coronary artery bypass grafting [25].
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Directions for future research
However, there are several limitations to the current evidence base for coronary CT. First, in patients with acute presentation, CT compared with established standard care reduced ICA rates but did not improve clinical outcomes [26]. Second, while artificial intelligence (AI) has potential to assess images and reduce workload of radiologists with high accuracy, there is limited implementation because little is known about which AI approaches might work best to individualise preventive (lipid lowering, anti-inflammatory and anti-thrombotic) therapy based on CT findings [17, 18]. Third, the current evidence in favour of CT is limited to patients with stable chest pain and an intermediate likelihood of obstructive CAD [14], suggesting that further multidisciplinary research is needed to assess patients on other ends of the clinical spectrum in which the use of CT in suspected CAD can be expected to be beneficial.
Despite these limitations, it is clear that multidisciplinary research has already built important bridges in the diagnosis and treatment of CAD and can serve as a bridgehead to further link radiology with the other disciplines to undertake even more ambitious efforts of non-invasive and quantitative cardiovascular imaging research to improve the care of our cardiovascular patients in the future.
Recommendations for clinical practice and directions for future research
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Better prevention of cardiovascular events with the help of non-invasive imaging for the characterisation and quantification of coronary atherosclerosis. Early detection of coronary atherosclerosis by CT may lead to increased use of preventive therapy which results in fewer cardiovascular events.
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Individual determination of treatment strategy becomes possible using non-invasive imaging for determining individually the presence and extent of CAD. Non-invasive assessment of obstructive CAD by CT for individualised decision-making about who may benefit most from revascularisation with additional functional tests.
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Improved procedural planning for the revascularisation strategy in patients with obstructive CAD. CT provides imaging biomarkers that could be used to guide revascularisation planning in individual patients in the future.
Acknowledgements
This article is a part of the ESR Bridges series. The Guest Editor for the ESR Bridges is Regina Beets-Tan (Amsterdam/NL). This publication is based on a joint session of the four authors at connAction 2023.
Declarations
Guarantor
The scientific guarantor of this publication is Marc Dewey.
Conflict of interest
Prof. Dewey has received grant support from the FP7 Program of the European Commission for the randomised multicentre DISCHARGE trial (EC-GA 603266 in HEALTH.2013.2.4.2-2). He also received grant support from German Research Foundation (DFG) in the Heisenberg Program (DE 1361/14-1, DFG project number 213705389), graduate program on quantitative biomedical imaging (BIOQIC, GRK 2260/1, DFG project number 289347353), for fractal analysis of myocardial perfusion (DE 1361/18-1, DFG project number 392304398), the DFG Priority Programme Radiomics (DFG project number 402688427) for the investigation of coronary plaque and coronary flow (DE 1361/19-1 [DFG project number 428222922] and DE 1361/20-1 [DFG project number 428223139] in SPP 2177/1), the GUIDE-IT project on data sharing of medical imaging trials (DE 1361/24-1 [DFG project number 495697118]), the Quantitative Cardiovascular Imaging (QCI) meeting (DE 1361/22-1) and the Future of Medical Imaging meeting (DE 1361/28-1). He also received funding from the Berlin University Alliance (GC_SC_PC 27) and from the Digital Health Accelerator of the Berlin Institute of Health. Prof. Dewey is European Society of Radiology (ESR) Publications Chair (2022–2025); and the opinions expressed in this article are the author’s own and do not represent the view of ESR. Per the guiding principles of ESR, the work as Publications Chair is on a voluntary basis and only remuneration of travel expenses occurs. Prof. Dewey is also the editor of Cardiac CT, published by Springer Nature, and offers hands-on courses on CT imaging (www.ct-kurs.de). Institutional master research agreements exist with Siemens, General Electric, Philips and Canon. The terms of these arrangements are managed by the legal department of Charité – Universitätsmedizin Berlin. Professor Dewey holds a joint approved patent with Florian Michallek on dynamic perfusion analysis using fractal analysis (EPO 2022 EP3350773A1, and USPTO 2021 10,991,109).
Prof. Vliegenthart is Deputy Editor for Radiology. Prof. Vliegenthart has received institutional research grants from Siemens Healthineers, and honorarium for lectures from Siemens Healthineers and Bayer Healthcare. Prof. Vliegenthart has received funding from the Dutch Cancer Foundation, Dutch Heart Foundation and Innovative Medical Devices Initiative/Netherlands Organisation for Health Research and Development. She is the current President of the European Society of Cardiovascular Radiology.
Statistics and biometry
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Methodology
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