Promises and pitfalls of relying on angiography-derived indexes to identify myocardial ischemia: A tale of Romulus and R
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Service of Hybrid Cardiac Imaging, Madonna Della Fiducia Clinic, Rome, Italy Department of Medical-Surgical Sciences and Biotechnologies, Sapienza University of Rome, Latina, Italy Mediterranea Cardiocentro, Naples, Italy ` Operativa Complessa di UTIC Emodinamica e Cardiologia, Ospedale Santa Maria Goretti, Unita Latina, Italy Ostia Radiologica, Rome, Italy Replycare, Rome, Italy
Received Jul 16, 2020; accepted Jul 16, 2020 doi:10.1007/s12350-020-02313-y
See related article, https://doi.org/10.10 07/s12350-020-02242-w. Rome wasn’t built in a day. John Heywood Ischemic heart disease (IHD) still represents a clinical challenge despite many decades of intense efforts aimed at optimizing prevention, diagnosis, risk stratification, treatment, and rehabilitation.1 While IHD recognizes several causes and pathophysiologic mechanisms, coronary artery disease (CAD) due to atherothrombosis maintains a pivotal role in determining IHD, especially in its most clinically impactful manifestations.2 Historically, efforts at elucidating the diagnosis and prognosis of CAD have focused on two independent and actually opposing perspective: a functional one, based on the characterization of myocardial viability, perfusion, or function, and an anatomical one, based on the definition of actual anatomic extent of CAD, either from a solely luminological perspective, or also including plaque and vessel wall characterization.3
Funding None. Reprint requests: Francesco Nudi, MD, Service of Hybrid Cardiac Imaging, Madonna Della Fiducia Clinic, Rome, Italy; [email protected] J Nucl Cardiol 1071-3581/$34.00 Copyright Ó 2020 American Society of Nuclear Cardiology.
This contrast between function and anatomy reminds of the struggle between Romulus and Remus.4 Indeed, just as any alliance is better than actual fight, modern cardiovascular imaging should arguably be founded on the optimal integration (i.e., fusion or hybrid imaging) between functional and anatomic detail, in order to better elucidate in an multidimensional yet integrative fashion all patient features, which may range from diagnosis, subgroup, risk, prognosis, warranty period, and therapeutic choice.5,6 Despite this rosy prophecy, the road to optimal integration of functional and anatomic cardiac data remains a challenging one, reminding indeed of the long time required to build from scratch a city, especially a complex and monumental one.4 Several hurdles must indeed be overcome to effectively and efficiently use hybrid imaging, but the main one rests in the eye of the beholder: to discard prior paradigms based on the test control comparison, in which a new test is appraised against to an established one (often considered a ‘‘gold standard’’).7 Indeed, considering a functional test as a valid comparator of an anatomic one, or vice versa, misses the whole point of patient-centered integration of multimodality imaging.8 This logical step is, however, challenging for many, including ourselves. Yet we need to recognize that, for instance, using invasive coronary angio
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