In this EACVI clinical scientific update, we will explore the current use of multi-modality imaging in the diagnosis, risk-stratification and follow-up of patients with aortic stenosis, with a particular focus on recent developments and future directions. Echocardiography is and will likely remain the key method of diagnosis and surveillance of aortic stenosis providing detailed assessments of valve haemodynamics and the cardiac remodelling response. CT is already widely used in the planning of transcutaneous aortic valve implantation. We anticipate its increased use as an anatomical adjudicator to clarify disease severity in patients with discordant echocardiographic measurements. CT calcium scoring is currently used for this purpose, however contrast computed tomography techniques are emerging that allow identification of both calcific and fibrotic valve thickening. Additionally, improved assessments of myocardial decompensation with echocardiography, cardiac magnetic resonance and computed tomography will become more commonplace in our routine assessment of aortic stenosis. Underpinning all of this will be widespread application of artificial intelligence. In combination we believe this new era of multi-modality imaging in aortic stenosis will improve the diagnosis, follow-up and timing of intervention in aortic stenosis as well as potentially accelerate the development of the novel pharmacological treatments required for this disease.

No abstract

Ticagrelor is a potent and orally active P2Y12 inhibitor. Ticagrelor has been extensively tested in Phase II and Phase III trials in patients with coronary artery disease. The pharmacokinetics and pharmacodynamics of Ticagrelor result in more rapid and effective inhibition of platelet activation compared with other P2Y12 inhibitors. This has resulted in a reduction in recurrent major cardiovascular events in initial randomized controls trials comparing Ticagrelor with clopidogrel. More recently, clinical trials have investigated the use of Ticagrelor in patients with stable coronary artery disease and a high residual risk of coronary thrombotic events. In patients with stable coronary artery disease, the potent antiplatelet effect of Ticagrelor is counterbalanced by an increased risk of major bleeding. Further research is ongoing to determine the optimal duration of Ticagrelor therapy.

Despite recent advances, cardiovascular disease remains the leading cause of death globally. As such, there is a need to optimise our current diagnostic and risk stratification pathways in order to better deliver individualised preventative therapies. Non-invasive imaging of coronary artery plaque can interrogate multiple aspects of coronary atherosclerotic disease, including plaque morphology, anatomy and flow. More recently, disease activity is being assessed to provide mechanistic insights into in vivo atherosclerosis biology. Molecular imaging using positron emission tomography is unique in this field, with the potential to identify specific biological processes using either bespoke or re-purposed radiotracers. This review provides an overview of non-invasive vulnerable plaque detection and molecular imaging of coronary atherosclerosis.

No abstract