Volume 16, Issue 12, December 2023, Pages 1608-1622Author links open overlay panel, , , , , , , Abstract

Coronary artery disease is the leading cause of morbidity and mortality worldwide. Despite remarkable advances in the management of coronary artery disease, the prediction of adverse coronary events remains challenging. Over the preceding decades, considerable effort has been made to improve risk stratification using noninvasive imaging. Recently, these efforts have increasingly focused on the direct imaging of coronary atherosclerotic plaque. Modern imaging now allows imaging of coronary plaque burden, plaque type, atherosclerotic plaque activity, and plaque thrombosis, which have major potential to refine patient risk stratification, aid decision making, and advance future clinical practice.

Section snippetsFocus on coronary atherosclerotic plaque

For many decades, myocardial ischemia imaging has been used to identify and to manage patients with coronary artery disease. This approach is based on the rationale that ischemia is responsible for patient symptoms and that consistent studies across multiple imaging modalities have demonstrated the robust association between myocardial ischemia and the future risk of myocardial infarction.6, 7, 8, 9, 10, 11, 12, 13, 14, 15 However, multiple randomized controlled trials have recently established

Development of atheroma

Atherosclerosis is initiated by the deposition of cholesterol within the arterial intima, most frequently at sites of low shear stress and endothelial dysfunction. Subsequent low-density lipoprotein cholesterol oxidation leads to an inflammatory response with infiltration of T lymphocytes and macrophages.25 The latter consume oxidized low-density lipoprotein cholesterol and form foam cells. These initial lesions often remain quiescent for many years or even regress. However, in the presence of

Key plaque factors associated with risk of myocardial infarction

Based on the underlying pathology and recent clinical trial data, 4 factors emerge as key players contributing to the overall risk of myocardial infarction. These factors can be combined to form 4 central determinants of risk comprising plaque burden, plaque type, atherosclerotic plaque activity, and plaque thrombosis (Central Illustration). It builds upon the triangle of risk proposed by Arbab-Zadeh and Fuster5 but focuses on noninvasive imaging and includes assessment of atherosclerotic

Plaque type

The knowledge that certain plaque phenotypes are more closely associated with plaque rupture and myocardial infarction has led to intense interest in the concept of the vulnerable plaque and the development of novel methods to detect adverse plaque characteristics in patients with clinically stable disease (Figure 2).25,29 Initial efforts were based around invasive imaging strategies, predominantly intravascular ultrasound (IVUS) and optical coherence tomography (OCT), culminating in the

Controversies

The rapid progress in plaque imaging has provided invaluable methods for depicting plaque type, burden, activity, and thrombosis. However, this has resulted in several controversies perhaps reflecting the nascent nature of this field. It remains to be determined if and how measures of plaque burden might be optimized for clinical use and whether these can improve clinical outcomes. There is also debate as to which type of plaque will provide the most useful clinical information. Some experts

Future perspectives

Modern noninvasive imaging now allows interrogation of plaque burden, type, activity, and thrombosis. While further optimization and observational studies are required, the next key step is to investigate how best to use this information in clinical practice. Many physicians already use the presence of coronary plaque identified on imaging as a trigger to prescribe preventative therapies, such as statins and aspirin, with international guidelines recommending the use of CT calcium scoring to

Conclusions

We stand at the threshold of a new era in the assessment of coronary artery disease with an increasing focus on the atherosclerotic plaque and the pathological processes leading to myocardial infarction, in particular, the assessment of plaque burden, which is already of clinical utility and set to develop further, with markers of plaque type, disease activity, and plaque thrombosis also holding promise in improving patient risk stratification and enabling a personalized medicine approach to

Funding Support and Author Disclosures

Dr Newby (CH/09/002, RE/18/5/34216, RG/16/10/32375), Dr Dweck (FS/14/78/31020), and Dr Williams (FS/11/014, CH/09/002, FS/ICRF/20/26002) are supported by the British Heart Foundation. Dr Tzolos was supported by a grant from Dr Miriam and the Sheldon G. Adelson Medical Research Foundation. Dr Newby is the recipient of a Wellcome Trust Senior Investigator Award (WT103782AIA) and Dr Dweck of the Sir Jules Thorn Award for Biomedical Research Award (2015). Dr Dey (R01HL133616) and Dr Slomka

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© 2023 by the American College of Cardiology Foundation. Published by Elsevier.