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Controversies in ACS

Non-Invasive Imaging

Dr. S. Raman presented the different CMR-related modalities in visualizing the myocardium at risk in patients with ACS highlighting the pro and contra of each tool. She underpinned the importance of correcting infarct size by area at risk in clinical trials testing the additive/adjunctive reperfusion strategies in patients with acute ST-segment elevation myocardial infarction.
  Dr Bodi reported the importance of comprehensive CMR studies in high-risk patients with acutely reperfused ST-segment elevation myocardial infarction to improve the decision-making and risk stratification. In particular, in patients with concomitant non-culprit vessel stenosis, the CMR protocol should be implemented with stress-perfusion in order to plan revascularization.
Dr Croiselle underlined the limitation of T2w-STIR imaging for the identification and quantification of myocardium at risk in patients with acute myocardial infarction. Remarkably, the strategies capable in improving salvaged myocardium (eg, post-conditioning) may potentially reduce the extent of myocardial edema leading to an underestimation of area at risk. This issue definitively warrants further investigations, potentially using quantitative T2 imaging, since the reduction of myocardial edema may lead to underestimation of treatment effectiveness.
Finally, Dr McConnell nicely described the recent advancements in imaging the coronary artery by CMR with particular respect to plaque/coronary wall characterization using T2w and post-contrast imaging. These novel findings may pave the way for non-invasive identification of high-risk coronary plaque prone to disruption. 


Controversies in Acute Coronary Syndrome
The content of this article reflects the personal opinion of the author/s and is not necessarily the official position of the European Society of Cardiology.