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Published on: January 28, 2020
Future strategies in the management of coronary artery disease
1University Hospital Zurich, Raemistrasse 100, CH-8091 Zurich, Switzerland and, Consultant Cardiac MR Center, Children's University Hospital Zurich, Switzerland. juerg.schwitter@usz.ch
Insights
New diagnostic techniques offer improved detection of coronary artery disease (CAD), shifting management from reactive to proactive strategies. This aims to prevent acute myocardial infarcts by identifying and treating patients earlier.
Area of Science:
- Cardiology
- Diagnostic Imaging
- Health Economics
Background:
- Coronary artery disease (CAD) management is suboptimal, with up to 60% mortality linked to insufficient diagnostic strategies.
- Current reactive approaches often fail to prevent acute myocardial infarcts.
- There is an urgent need for improved diagnostic methods and a shift towards active CAD management.
Purpose of the Study:
- To critically review the pathophysiology of CAD and current concepts of coronary atherosclerosis.
- To propose a transition from a reactive to an active strategy for CAD management.
- To provide an overview of current and future diagnostic tests for CAD, evaluating their reliability, repeatability, cost-effectiveness, and patient comfort.
Main Methods:
- Critical review of existing literature on CAD pathophysiology and atherosclerosis.
- Analysis of novel and current diagnostic techniques, including tomographic methods.
- Proposal of mathematical tools for test selection and patient subset identification using data from trials and registries.
Main Results:
- Novel tomographic techniques show promise for standardization and reproducibility, crucial for performance and cost-effectiveness assessment.
- High CAD prevalence and restricted healthcare resources necessitate cost-effective diagnostic solutions.
- Mathematical tools can objectively aid in selecting optimal CAD diagnostic tests and identifying patient groups benefiting from active management.
Conclusions:
- A proactive strategy for CAD detection and treatment is essential to reduce mortality.
- Novel tomographic techniques and mathematical modeling offer promising avenues for improving CAD diagnosis and management.
- Future efforts should focus on developing and validating cost-effective, reliable diagnostic tools for an active CAD management approach.
Abstract:
New diagnostic techniques have now become available that will enable us to obtain information on coronary artery disease (CAD), which was not previously possible. This is urgently needed, since changes in CAD management are highly desirable considering that up to 60% of patients die due to an insufficient diagnostic strategy (reactive strategy). In this article, the pathophysiology of CAD and the evidence of current concepts on coronary atherosclerosis are critically reviewed. Consequently, a shift from a 'reactive strategy' of CAD management to an active strategy is proposed in order to detect and treat patients before acute myocardial infarcts occur. Reliability, repeatability, cost-effectiveness and comfort are important features of an optimal test for this active strategy. This perspective gives an overview of current and future tests with respect to these features. The novel tomographic techniques are particularly promising with respect to standardization and reproducibility, which will set the basis for the determination of test performance and, consequently, cost-effectiveness. Assessment of cost-effectiveness is increasingly important, since prevalence of CAD is high and will most likely increase, while resources will remain restricted in most countries. Considering these economic restrictions, this article also proposes new mathematical tools using data from prospective trials and large international registries as an objective means to select the best tests for CAD diagnosis and management, and to identify those patient subsets which benefit most from an active strategy.
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