Heart Attack

Imaging provides a more precise diagnosis of a heart attack that can be used to individualise treatment. That’s the main message of an expert consensus paper published today in European Heart Journal, a journal of the European Society of Cardiology (ESC), and present at EuroPCR in Paris, France.Heart attacks are diagnose and treat using coronary angiography, an invasive procedure which provides an X-ray outline of the arteries supplying blood to the heart.

The coronary syndromes

Invasive imaging of the arteries gives more detail but there has controversy over when to use it. This document seeks to resolve that debate. It promotes the adoption of intra coronary imaging in two major areas: acute coronary syndromes including heart attack and when diagnostic information from angiography is unclear.

Which patients and lesions merit imaging? For acute coronary syndromes, advice is given on atypical presentation, complex lesions, and non-obstructive coronary artery disease. The paper provides criteria for assessment of the arteries, interpretation of images, choice of treatment, and guidance during stent insertion (percutaneous coronary intervention; PCI). In the past it was thought that most acute coronary syndromes were caused by ruptured plaque.

Intracoronary imaging has identified plaque erosion and eruptive calcified nodules as other causes which may benefit from different treatment. In addition, intracoronary imaging clearly shows thrombus, which angiography may miss or misidentify. Imaging is more accurate, helps guide decisions and facilitates tailor therapy, especially in younger heart attack patients who more frequently have plaque erosion or non-atherosclerotic coronary artery disease,” said senior author Dr. Giulio Guagliumi.

Ambiguous during heart attacks

Coronary angiography is often ambiguous during heart attacks; which lack an identifiable culprit lesion or have multiple culprit lesions. Intracoronary imaging provides clarity before and during PCI. An ageing population and rising levels of diabetes mean that more lesions causing heart attacks are calcified; which is difficult to detect using angiography and more challenging for PCI. In addition, angiography may be hazy for certain anatomies such as tortuous vessels and aneurysms.

Patients refer for PCI increasingly have comorbidities and complex coronary artery disease. Dr. Guagliumi said: Intracoronary imaging is particularly useful in complex patient; also lesion scenarios and the paper states settings where it would provide maximum benefit for instance patients; so with non ST elevation acute coronary syndromes, calcified vessels, long lesions or in-stent restenosis.

There is more to gain clinically through developments in these areas. They conclude: The role of intravascular imaging to diagnose acute coronary syndromes, select treatment, and guide PCI will continue to grow. With it we expect to achieve superior long-term outcomes.

The document was written by a panel organise by the European Association of Percutaneous Cardiovascular Interventions (EAPCI) and is part 2 of a series on the clinical use of intra coronary imaging. Part 1 focused on stent selection and optimisation criteria. Both documents discuss intra vascular ultrasound (IVUS) and optical coherence tomography (OCT).