‘We know more about disease than health,’ but advances in CV imaging may change that
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Even in the COVID-19 era, atherosclerotic CVD remains the leading cause of death worldwide.
One possible reason is: “We know more about disease than health,” Valentin Fuster, MD, PhD, MACC, president of Mount Sinai Heart, physician-in-chief at The Mount Sinai Hospital and the Richard Gorlin, MD/Heart Research Foundation Professor at the Icahn School of Medicine at Mount Sinai, said during the American College of Cardiology New York Cardiovascular Symposium, which he chaired.
That being said, 2022 brought numerous advances in the diagnosis and characterization of atherosclerosis and new methods and strategies for its prevention and treatment, which were summarized at the symposium.
Fuster kicked off a comprehensive review of the year’s progress in combating heart disease with a provocative challenge to address prevention of ASCVD starting in childhood. He reminded the audience that atherosclerosis is often well established by age 20 years, but remains asymptomatic until age 40 or 50 years. He posited that early application of preventive lifestyle measures at the family, community and organizational level with global attention to climate and the environment would be very cost-effective in improving global CV health.
Fuster also promoted programs for comprehensive risk assessment in asymptomatic individuals, including the use of CT and ultrasonic imaging to identify non-flow-limiting atherosclerotic disease, followed by early and vigorous intervention to treat causal factors including hyperlipidemia, obesity, glucose intolerance and hypertension, coupled with aggressive societal approaches to reduce environmental challenges to CV health. He said our goal should be to direct more of our resources to prevention and early intervention rather than focusing exclusively on reacting to the consequences of advanced atherosclerotic disease.
“Guidelines should not start at age 40 or 50 with symptomatic disease,” Fuster said.
Also at the symposium, Ron Blankstein, MD, FACC, FASNC, MSCCT, FASPC, associate director of the cardiovascular imaging program, the director of cardiac computed tomography, co-director of the cardiovascular imaging training program at Brigham and Women’s Hospital and professor of medicine at Harvard Medical School, reviewed recent advances in the imaging of ASCVD, focusing on trials using CT coronary angiography, including results of the PRECISE trial, reported in November at the American Heart Association Scientific Sessions by Pamela S. Douglas, MD, MACC, FASE, FAHA, Ursula Geller Professor of Research in Cardiovascular Diseases at Duke University and past president of the ACC.
A comparison of patients with stable angina evaluated with coronary CTA and CT-derived fractional flow reserve (HeartFlow) vs. a traditional strategy focused on stress testing and invasive coronary angiography showed improved accuracy using the coronary CTA approach with fewer unnecessary follow-up tests and higher rates of cholesterol and antiplatelet medication use, adding further support for the ACC/AHA/Multisociety Guideline for the Evaluation and Diagnosis of Chest Pain issued in October 2021 that elevated the use of coronary CTA in appropriate patients with stable chest pain to a class I recommendation.
Blankstein also reviewed developing concepts of atherosclerotic plaque analysis using artificial intelligence and machine learning tools to go beyond calcium scoring and assessment of flow-limiting stenoses to measure total plaque volume as well as characterization of individual lesions.
Total plaque could be a major target for early therapy. Coronary CTA may play a central role not only in directing patients to appropriate interventional therapy to relieve stenoses, but also to assist in assessing the efficacy of new generations of antiatherosclerotic medications aimed at prevention or even regression of nonstenotic plaques. New applications of CT reported at the fall meeting of the Society of Cardiovascular Computed Tomography introduced algorithms were aimed at assessing pericoronary fat to track inflammation around vulnerable plaques, a potential therapeutic target.
Broad and rapid progress has been made in CT instrumentation since CT was first applied to screening for atherosclerotic coronary calcification 30 years ago. Multiple presentations at the annual Radiological Society of North America meeting earlier in December showcased technologic developments in CT including improved resolution and reduction of calcium and stent artifacts using lower radiation doses using new techniques employing spectral imaging with photon counting technology. We can expect this new imaging technology coupled with advances in AI, machine learning and radiomics to continue to improve our knowledge of both health and disease.
References:
- Blankstein R. Evolving New Frontiers and Imaging Ready for Practice. Presented at: American College of Cardiology New York Cardiovascular Symposium; Dec. 9-11, 2022; New York.
- Douglas PS, et al. LBS.06: Drugs and Strategies in ACS and Revascularization. Presented at: American Heart Association Scientific Sessions; Nov. 5-7, 2022; Chicago (hybrid meeting).
- Fuster V. Evolving New Frontiers and Imaging Ready for Practice. Presented at: American College of Cardiology New York Cardiovascular Symposium; Dec. 9-11, 2022; New York.
- Gulati M, et al. Circulation. 2021;doi:10.1161/CIR.0000000000001030.
For more information:
L. Samuel Wann, MD, MACC, FESC, is a cardiovascular specialist at the University of New Mexico and editor of the Practice Management section for Cardiology Today. He can be reached at samuelwann@gmail.com; Twitter: @samuel_wann.
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