Non-Invasive Modalities in the Assessment of Vulnerable Coronary Atherosclerotic Plaques

Abstract

Coronary atherosclerosis is a complex, multistep process that may lead to critical complications upon progression, revolving around plaque disruption through either rupture or erosion. Several high-risk features are associated with plaque vulnerability and may add incremental prognostic information. Although invasive imaging modalities such as optical coherence tomography or intravascular ultrasound are considered to be the gold standard in the assessment of vulnerable coronary atherosclerotic plaques (VCAPs), contemporary evidence suggests a potential role for non-invasive methods in this context. Biomarkers associated with deleterious pathophysiologic pathways, including inflammation and extracellular matrix degradation, have been correlated with VCAP characteristics and adverse prognosis. However, coronary computed tomography (CT) angiography has been the most extensively investigated technique, significantly correlating with invasive method-derived VCAP features. The estimation of perivascular fat attenuation as well as radiomic-based approaches represent additional concepts that may add incremental information. Cardiac magnetic resonance imaging (MRI) has also been evaluated in clinical studies, with promising results through the various image sequences that have been tested. As far as nuclear cardiology is concerned, the implementation of positron emission tomography in the VCAP assessment currently faces several limitations with the myocardial uptake of the radiotracer in cases of fluorodeoxyglucose use, as well as with motion correction. Moreover, the search for the ideal radiotracer and the most adequate combination (CT or MRI) is still ongoing. With a look to the future, the possible combination of imaging and circulating inflammatory and extracellular matrix degradation biomarkers in diagnostic and prognostic algorithms may represent the essential next step for the assessment of high-risk individuals.

Vulnerable Atherosclerotic Plaque: Is There a Molecular Signature?

“…There is a growing interest in miRNA playing a role in coronary artery syndromes and in their potential diagnosis and prognosis role illustrated by numerous studies and reviews that covered this issue: Kumric et al [ 137 ], Guo et al [ 138 ], Theofilis et al [ 139 ], and Kong et al [ 140 ]. Some new and interesting information may be added to these descriptive reviews.…”

Efficacy of intravascular lithotripsy (IVL) in coronary stenosis with severe calcification: A multicenter systematic review and meta‐analysis

“…[1][2][3] Particularly in the coronary bed, arterial calcification indicates an early stage of atherosclerosis, occurring in 67% of women and 90% of men aged 70 or older. 4,5 Progressive coronary artery calcification (CAC) leads to severe cases of coronary artery disease (CAD), which encompasses the clinical presentations of stable and unstable angina, myocardial infarction (MI), or sudden cardiac death. [4][5][6][7][8] The presence of CAC is increasingly observed and significantly limits technical success during percutaneous coronary interventions (PCI).…”

“…4,5 Progressive coronary artery calcification (CAC) leads to severe cases of coronary artery disease (CAD), which encompasses the clinical presentations of stable and unstable angina, myocardial infarction (MI), or sudden cardiac death. [4][5][6][7][8] The presence of CAC is increasingly observed and significantly limits technical success during percutaneous coronary interventions (PCI). 9 During percutaneous interventions, arterial calcification limits coronary vessel expansion, leading to recoil and dissections in the acute setting and to limited durability in the long term.…”

“…This generates vascular calcification and stiffness, a prevalent disorder mainly associated with older age, diabetes mellitus, dyslipidemia, and chronic kidney disease, all representing cardiovascular risk factors 1–3 . Particularly in the coronary bed, arterial calcification indicates an early stage of atherosclerosis, occurring in 67% of women and 90% of men aged 70 or older 4,5 . Progressive coronary artery calcification (CAC) leads to severe cases of coronary artery disease (CAD), which encompasses the clinical presentations of stable and unstable angina, myocardial infarction (MI), or sudden cardiac death 4–8 .…”

Standardized CT Value: A Promising Diagnostic Parameter to Differentiate Lipid and Fibrous Coronary Plaques

“…Intravascular ultrasound (IVUS) is accepted as the gold standard for identifying the nature of plaques in vivo. However, this approach has not been widely adopted in daily practice due to its relatively high cost, the prevalence of complications and the invasiveness of the operation [4] .…”