Identifying the progression of coronary artery disease: prediction of cardiac events

Coronary artery disease (CAD) remains as a principal cause of morbidity and mortality worldwide. Despite the advancements in medical therapy and interventional procedures during the past years, the rate of major adverse cardiac events remains high both in individuals without previous history of heart disease and in patients with known CAD. Improved strategies of risk stratification for identifying subclinical atherosclerosis and asymptomatic individuals at high risk for cardiac events may help in intensifying treatment at targeted population groups, thereby providing enhanced primary prevention. Latest technological progress has made available new methodologies (e.g., fractional flow reserve and virtual surrogates) for assessing coronary anatomy and obstructive lesions precipitating acute cardiac events. Coronary imaging using either invasive (e.g., intravascular ultrasound, optical coherence tomography) or noninvasive (e.g., multislice computed tomography) modalities has enabled the detailed identification of atherosclerotic plaque features and inflammatory processes, thereby providing a “histology-like” quantification of the disease burden within coronary arteries. Additionally, the local hemodynamic environment, in particular endothelial shear stress, is considered as a primary stimulus for plaque development and progression. In vivo assessment of endothelial shear stress in humans has been made possible using three-dimensional coronary imaging and computational fluid dynamics techniques, and could potentially provide a more comprehensive evaluation of the risk for disease progression. Combined assessment of cardiovascular burden focusing on the functional significance of obstructive CAD, the anatomic features of plaque vulnerability, and the local hemodynamic milieu could yield an increased predictive capacity for prognostication, and thus enable preemptive strategies that could avert cardiac events.

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