Two trends will facilitate this process. First, technical developments. It seems clear that echocardiography is and will be in the foreseeable future the work-horse of cardiac imaging. In echocardiography progress is in two directions: advanced ultrasound systems with sophisticated options for more quantitative processes; and the
development of hand-held miniature echo devices. With respect to the former, current limitations in the visual subjective analysis of echo images will be overcome within the next couple of years by using automatic detection of structures such as cardiac walls (Figure 1).
The second trend will bring echocardiography to the bedside in a role not unlike the stethoscope's. These developments obviously outburst the need of imaging training for doctors.
Another good example of a recent technical advance is the development of multi-slice CT which makes possible non-invasive diagnostic-quality coronary angiography. The most recent innovation has been with imaging devices which consist of two different scanners in the same package. The idea here is that the two systems complement each other: the one is producing high resolution anatomical images and the other functional information such as myocardial perfusion.
These systems are likely to change fundamentally the field of imaging in coronary artery diseas
e because they allow both the comprehensive imaging of cardiac function and quantitative perfusion with anatomical coregistration in less than half of an hour (Figure 2). Currently, the combination of multi-slice CT with gamma cameras or PET has become rapidly very popular. A combination of PET and MRI is also available.
The strength of MRI is the radiation-free accurate imaging of cardiac structures. This has been very useful in structurally complicated congenital heart diseases. The unique characteristics of MRI include the characterisation of tissue in high spatial resolution and detection of myocardial inflammatory diseases. It is likely that in the near future the imaging protocols will become faster as more disease specific contrast agents become available.
The second trend in imaging is in personalised medicine. This means that the demanding and expensive treatments of the future will be targeted and patients carefully selected. It also means that imaging techniques, especially molecular imaging, may have a pivotal role. Nuclear imaging, especially PET, provides a unique and powerful method to bridge the gap between molecular biology, pathophysiology and targeted treatment. It is expected that the more specific imaging targets, such as plaque or gene expression, will have clinical applications. The more pronounced role of imaging in therapy is also possible. Targeted drug delivery using ultrasound is one potential application under investigations.
It is of great interest how these trends will change costs and cost-effectiveness. There are several trials studying the cost-related issues of current techniques. Advanced imaging, of course, is more expensive, but so are the new therapies. So one of the likely scenarios is that advanced imaging is necessary to target those therapies more accurately, and thereby make significant savings by more tailored therapy roadmapping.