Integrating Anatomy and Ischemia in Chest Pain Evaluation

Area of Science:

• Cardiology
• Medical Imaging
• Diagnostic Strategies

Background:

• Coronary atherosclerosis is a major cause of death and illness.
• Optimal patient evaluation requires integrating anatomic and physiologic data.
• Current diagnostic approaches involve a range of noninvasive and invasive techniques.

Purpose of the Study:

• To review current evidence on evaluating coronary atherosclerosis.
• To outline contemporary clinical pathways for disease assessment.
• To inform evidence-based practice for improved patient outcomes.

Main Methods:

• Review of noninvasive imaging: coronary CT angiography (CCTA), CT-derived fractional flow reserve (CT-FFR), stress echocardiography, SPECT, PET myocardial blood flow/coronary flow reserve, stress cardiac magnetic resonance (CMR).
• Review of invasive methods: coronary angiography with fractional flow reserve (FFR)/instantaneous wave-free ratio (iFR), intravascular ultrasound (IVUS), optical coherence tomography (OCT).
• Synthesis of diagnostic performance data and clinical pathway guidelines.

Main Results:

• Noninvasive strategies efficiently triage patients and characterize coronary artery disease.
• Invasive methods provide lesion-specific information crucial for revascularization decisions.
• Clinical pathways typically start with anatomy, add physiology for intermediate-high risk, and escalate to invasive assessment when needed.
• Patient-specific factors influence the choice of diagnostic modality.

Conclusions:

• Integrating anatomic and physiologic assessment is key for evaluating coronary atherosclerosis.
• Evidence-based clinical pathways and modality selection improve diagnostic accuracy.
• Optimizing diagnostic strategies leads to better patient management and outcomes in coronary artery disease.