Imaging has gained attention in many areas of medicine but its relevance and importance in clinical cardiology cannot be underestimated. While chest X-ray and heart radioscopy have been used for many decades, it is the maturation of echocardiography which has propelled non-invasive imaging to the foreground of our diagnostic arsenal in cardiology. More recently, cardiovascular magnetic resonance and computed tomography have joined this club.
In the mean time nuclear medicine has grown a steady and impressive mountain of evidence as a gatekeeper in ischemic heart disease through SPECT imaging and has increased our knowledge about many aspects of the pathophysiology of heart disease through PET imaging.
But invasive imaging has also evolved significantly, with the addition not only of therapeutic procedures but also of more refined imaging and diagnostic procedures, including echo (IVUS), flow velocity measurements, optical coherence tomography, palpography and pressure measurements.
The issue today no longer seem to be whether we can acquire images of a given anatomical or functional problem but rather what technique or modality we should use - since for many questions several options are available: C’est l’embarras du choix. Clinicians are confronted with a fast evolving arsenal of imaging techniques which all claim to be the optimal choice for their clinical question. Each imaging modality has the tendency to promote itself as the better technique and claim the holy grail of the “one-stop-shop”, an abhorrent term if ever one existed. Combine this with the push from industry to sell the newest and brightest (more slices, more parallel coils, more crystals, combine SPECT and CT, combine MR and PET...) and the inherent turf battle between the different specialities in cardiovascular imaging, and the clinician is left wondering at the sideline if he really needs any of this.
It is time to start focusing again, not on what we can image, but on what we need to image to improve patient diagnosis and outcome. This does not mean that new techniques are not welcome or dearly needed in many areas, but that we have to create evidence showing an incremental value above existing techniques before including them in everyday practice. We also have to create a new subspecialty of the cardiovascular “imager” who relays a clinical question into a stepwise approach to the different modalities and integrates the information coming from these various techniques into a consistent answer to the clinicians. This requires broad consensus-building among the different modalities and specialties and much more research into the area, but it is necessary to translate today’s expanding imaging capabilities into a benefit for the cardiovascular patient.