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The rapid advance of technology is securing an ever-greater role for imaging in the diagnosis and management of cardiovascular disease. European Association for Cardiovascular Imaging (EACVI) Past Secretary, and a speaker at a symposium this afternoon, Associate Professor Chiara Bucciarelli-Ducci (University of Bristol, Bristol, UK) gives her views on novel applications for cardiac imaging in ESC Clinical Practice Guidelines.
“In the latest ESC Guidelines on acute myocardial infarction in patients presenting with ST-segment elevation (STEMI), the role of non-invasive imaging has been refined giving physicians a much clearer indication of which test is indicated in the patient pathway (admission, hospital stay, discharge and follow-up).1 While echocardiography is clearly the first-line modality, cardiovascular magnetic resonance (CMR) is now explicitly recommended as a second-line imaging modality both during hospital admission and for follow up when echocardiography is suboptimal or inconclusive. In addition, the role of invasive and non-invasive testing in the diagnostic work-up of myocardial infarction and non-obstructed coronary arteries (MINOCA) was introduced for the first time and discussed. The Fourth Universal Definition of Myocardial Infarction also puts greater emphasis on CMR and the opportunity it provides to distinguish ischaemic from non-ischaemic myocardial injury and damage based on the pattern of myocardial oedema and scarring.2
In the ESC Guidelines on the diagnosis and management of chronic coronary syndromes (CCS), six clinical scenarios are presented and the application of various diagnostic tests in different patient groups to rule-in or rule-out coronary artery disease (CAD) have been updated.3 The main–and much awaited–novelty is the introduction of coronary computed tomography (CT) in the diagnostic work-up of patients with suspected CAD and angina or dyspnoea. The specific recommendations in imaging are:
1) Non-invasive functional imaging for myocardial ischaemia or coronary CT angiography (CTA) is recommended as the initial test to diagnose CAD in symptomatic patients in whom obstructive CAD cannot be excluded by clinical assessment alone (Ia).
2) It is recommended that selection of the initial non-invasive diagnostic test is done based on the clinical likelihood of CAD and other patient characteristics that influence test performance, local expertise and the availability of tests (Ic).
3) Functional imaging for myocardial ischaemia is recommended if coronary CTA has shown CAD of uncertain functional significance or is not diagnostic (Ib).
Imaging is recommended also for risk stratification, preferably stress imaging or coronary CTA (if permitted by local expertise and availability) or alternatively, exercise stress electrocardiogram (ECG) (if significant exercise can be performed and the ECG is amenable to the identification of ischaemic changes) in patients with suspected or newly diagnosed CAD (Ib).
Among the novel concepts in imaging in valvular heart disease4 is the introduction of the heart team in which the cardiovascular imager is an integral part. What’s new in aortic stenosis imaging is the additional clarity on assessing patients with suspected aortic stenosis and assuring its severity, as well as the extension of the diagnostic work-up for transcatheter aortic valve implantation (TAVI) in patients at low risk following the PARTNER 3 and Evolut trials. Also, the limitations of the 50% cut-off for left ventricular ejection fraction as a measure of left ventricular function in aortic stenosis is appraised along with the role of global longitudinal strain by echocardiography and myocardial scar detection by CMR. Following the MITRA-FR and COAPT trials, the role of echocardiography for secondary mitral regurgitation has been further developed and used to interpret the possible explanations about the different results.
I hope you can join me and Professors Knuuti, Bax and Popescu as we discuss the very latest role of imaging in acute and chronic coronary syndromes, heart failure and valvular heart disease.”
Role of cardiac imaging in current guidelines: what’s new? Today, 14:30 – 15:40; Amsterdam – Village 1
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1. 2017 ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation. Eur Heart J 2018;39:119–177. 2. Fourth universal definition of myocardial infarction (2018). Eur Heart J 2019;40:237–269. 3. 2019 ESC Guidelines for the diagnosis and management of chronic coronary syndromes. Eur Heart J 2019. doi/10.1093/eurheartj/ehz4254. 2017 ESC/EACTS Guidelines for the management of valvular heart disease. Eur Heart J 2017;38:2739–2791.
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