Assessing coronary disease in 2025

Sometimes I wonder how cardiology practice will changed in the next 20 years. Looking back to how we assessed people with suspected coronary artery disease little has changed in the last two decades. In 1994 we would make an approach with clinical history, examination and then use of the exercise ECG and performing invasive coronary angiography. Developments in imaging have spiralled with echo, MRI and CT all having a more and more domain role in patient assessment. What I believe will change cardiology in the next 20 years is the further development of cardiac CT as a method of not only showing the anatomy of the coronary arteries but going further and assessing the functional significance of any narrowing and the presence of high risk disease. 

Currently the 64 and 128 slice CT is is good at demonstrating normal coronary arteries in younger people but the technique is not so good in older people when the coronary arteries are calcified or when moderate disease is detected. In these situations cardiologist usually resort to invasive angiography.

CT research is driving forward the technique to make assessments of plaque morphology and plaque specific functional data. Current interest is in the measure of ESS which is the the tangential force generated by the friction of flowing blood on the endothelial surface of the arterial wall. In coronary segments with low and disturbed or turbulent flow (low ESS) endothelial cells express proatherogenic genes and development of high-risk lesions. In contrast straight arterial segments with undisturbed laminar flow (normal ESS) has endothelial cells express atheroprotective genes resulting in stable and quiescence plaques. Putting this together it seems that ESS might be a CT measure which can help the cardiologist decide if the patient is at increased risk of heart attack. CT is highly sensitive to identify atherosclerotic plaques this information could be assessed to other risk factor information to identify patients with subclinical CAD and vulnerable plaques. Combining the complex information obtained from CT would realize a more personalized approach to cardiovascular disease prevention and care for each patient.