Role of Cardiovascular Imaging in Risk Assessment: Recent Advances, Gaps in Evidence, and Future Directions

Francesco Perone¹, Marco Bernardi², Alban Redheuil³, Dario Mafrica², Edoardo Conte⁴, Luigi Spadafora², Fiona Ecarnot⁵, Lale Tokgozoglu⁶, Carlos G Santos-Gallego^{7

8}, Sergio Emanuel Kaiser⁹, Federica Fogacci¹⁰, Annabelle Sabouret¹¹, Deepak L Bhatt⁸, Francesco Paneni^{12

13}, Maciej Banach^{14

15}, Raul Santos¹⁶, Giuseppe Biondi Zoccai^{17

18}, Kausik K Ray¹⁹, Pierre Sabouret²⁰

Affiliations

¹ Cardiac Rehabilitation Unit, Rehabilitation Clinic "Villa delle Magnolie", Castel Morrone, 81020 Caserta, Italy.
² Department of Clinical, Internal Medicine, Anesthesiology and Cardiovascular Sciences, Sapienza University of Rome, 00185 Rome, Italy.
³ Laboratoire d'Imagerie Biomédicale, Sorbonne University, INSERM 1146, CNRS 7371, 75005 Paris, France.
⁴ Cardiology Department, Galeazzi-Sant'Ambrogio Hospital IRCCS, 20100 Milan, Italy.
⁵ Department of Cardiology, University Hospital Besancon, University of Franche-Comté, 25000 Besancon, France.
⁶ Department of Cardiology, Medical Faculty, Hacettepe University, 06230 Ankara, Turkey.
⁷ Atherothrombosis Research Unit, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA.
⁸ Mount Sinai Heart, Icahn School of Medicine at Mount Sinai Health System, New York, NY 10029, USA.
⁹ Discipline of Clinical and Experimental Pathophysiology, Rio de Janeiro State University, Rio de Janeiro 23070-200, Brazil.
¹⁰ Hypertension and Cardiovascular Risk Research Group, Medical and Surgical Sciences Department, Alma Mater Studiorum University of Bologna, 40126 Bologna, Italy.
¹¹ Gustave-Roussy Institute, Hérault Department, 94805 Villejuif, France.
¹² Department of Cardiology, University Heart Center, University Hospital Zurich, 8091 Zurich, Switzerland.
¹³ Center for Translational and Experimental Cardiology (CTEC), University Hospital Zurich and University of Zurich, 8091 Zurich, Switzerland.
¹⁴ Department of Preventive Cardiology and Lipidology, Medical University of Lodz (MUL), Rzgowska 281/289, 93-338 Lodz, Poland.
¹⁵ Cardiovascular Research Centre, University of Zielona Gora, 65-417 Zielona Gora, Poland.
¹⁶ Heart Institute, University of Sao Paulo Medical School, São Paulo 05403-903, Brazil.
¹⁷ Department of Medical-Surgical Sciences and Biotechnologies, Sapienza University of Rome, 00185 Roma, Italy.
¹⁸ Mediterranea Cardiocentro, 80122 Napoli, Italy.
¹⁹ Imperial Centre for Cardiovascular Disease Prevention and Imperial Clinical Trials Unit, Department of Public Health and Primary Care, Imperial College London, London SW7 2BX, UK.
²⁰ Heart Institute, Cardiology Department, Paris and National College of French Cardiologists, Pitié-Salpétrière Hospital, Sorbonne University, 75013 Paris, France.

PMID: 37685628
PMCID: PMC10487991
DOI: 10.3390/jcm12175563

Review

Role of Cardiovascular Imaging in Risk Assessment: Recent Advances, Gaps in Evidence, and Future Directions

Francesco Perone et al. J Clin Med. 2023.

. 2023 Aug 26;12(17):5563.

doi: 10.3390/jcm12175563.

Authors

Affiliations

¹ Cardiac Rehabilitation Unit, Rehabilitation Clinic "Villa delle Magnolie", Castel Morrone, 81020 Caserta, Italy.
² Department of Clinical, Internal Medicine, Anesthesiology and Cardiovascular Sciences, Sapienza University of Rome, 00185 Rome, Italy.
³ Laboratoire d'Imagerie Biomédicale, Sorbonne University, INSERM 1146, CNRS 7371, 75005 Paris, France.
⁴ Cardiology Department, Galeazzi-Sant'Ambrogio Hospital IRCCS, 20100 Milan, Italy.
⁵ Department of Cardiology, University Hospital Besancon, University of Franche-Comté, 25000 Besancon, France.
⁶ Department of Cardiology, Medical Faculty, Hacettepe University, 06230 Ankara, Turkey.
⁷ Atherothrombosis Research Unit, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA.
⁸ Mount Sinai Heart, Icahn School of Medicine at Mount Sinai Health System, New York, NY 10029, USA.
⁹ Discipline of Clinical and Experimental Pathophysiology, Rio de Janeiro State University, Rio de Janeiro 23070-200, Brazil.
¹⁰ Hypertension and Cardiovascular Risk Research Group, Medical and Surgical Sciences Department, Alma Mater Studiorum University of Bologna, 40126 Bologna, Italy.
¹¹ Gustave-Roussy Institute, Hérault Department, 94805 Villejuif, France.
¹² Department of Cardiology, University Heart Center, University Hospital Zurich, 8091 Zurich, Switzerland.
¹³ Center for Translational and Experimental Cardiology (CTEC), University Hospital Zurich and University of Zurich, 8091 Zurich, Switzerland.
¹⁴ Department of Preventive Cardiology and Lipidology, Medical University of Lodz (MUL), Rzgowska 281/289, 93-338 Lodz, Poland.
¹⁵ Cardiovascular Research Centre, University of Zielona Gora, 65-417 Zielona Gora, Poland.
¹⁶ Heart Institute, University of Sao Paulo Medical School, São Paulo 05403-903, Brazil.
¹⁷ Department of Medical-Surgical Sciences and Biotechnologies, Sapienza University of Rome, 00185 Roma, Italy.
¹⁸ Mediterranea Cardiocentro, 80122 Napoli, Italy.
¹⁹ Imperial Centre for Cardiovascular Disease Prevention and Imperial Clinical Trials Unit, Department of Public Health and Primary Care, Imperial College London, London SW7 2BX, UK.
²⁰ Heart Institute, Cardiology Department, Paris and National College of French Cardiologists, Pitié-Salpétrière Hospital, Sorbonne University, 75013 Paris, France.

PMID: 37685628
PMCID: PMC10487991
DOI: 10.3390/jcm12175563

Abstract

Optimal risk assessment for primary prevention remains highly challenging. Recent registries have highlighted major discrepancies between guidelines and daily practice. Although guidelines have improved over time and provide updated risk scores, they still fail to identify a significant proportion of at-risk individuals, who then miss out on effective prevention measures until their initial ischemic events. Cardiovascular imaging is progressively assuming an increasingly pivotal role, playing a crucial part in enhancing the meticulous categorization of individuals according to their risk profiles, thus enabling the customization of precise therapeutic strategies for patients with increased cardiovascular risks. For the most part, the current approach to patients with atherosclerotic cardiovascular disease (ASCVD) is homogeneous. However, data from registries (e.g., REACH, CORONOR) and randomized clinical trials (e.g., COMPASS, FOURIER, and ODYSSEY outcomes) highlight heterogeneity in the risks of recurrent ischemic events, which are especially higher in patients with poly-vascular disease and/or multivessel coronary disease. This indicates the need for a more individualized strategy and further research to improve definitions of individual residual risk, with a view of intensifying treatments in the subgroups with very high residual risk. In this narrative review, we discuss advances in cardiovascular imaging, its current place in the guidelines, the gaps in evidence, and perspectives for primary and secondary prevention to improve risk assessment and therapeutic strategies using cardiovascular imaging.

Keywords: cardiovascular imaging; cardiovascular risk; prevention; risk assessment.

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Conflict of interest statement

Prof. Bhatt discloses the following relationships: Advisory Board, Angiowave, Bayer, Boehringer Ingelheim, Cardax, CellProthera, Cereno Scientific, Elsevier Practice Update Cardiology, High Enroll, Janssen, Level Ex, McKinsey, Medscape Cardiology, Merck, MyoKardia, NirvaMed, Novo Nordisk, PhaseBio, PLx Pharma, Regado Biosciences, Stasys; Board of Directors, Angiowave (stock options), Boston VA Research Institute, Bristol Myers Squibb (stock), DRS.LINQ (stock options), High Enroll (stock), Society of Cardiovascular Patient Care, TobeSoft; Chair, Inaugural Chair, American Heart Association Quality Oversight Committee; Consultant, Broadview Ventures, Hims; Data Monitoring Committees, Acesion Pharma, Assistance Publique-Hôpitaux de Paris, Baim Institute for Clinical Research (formerly Harvard Clinical Research Institute, for the PORTICO trial, funded by St. Jude Medical, now Abbott), Boston Scientific (Chair, PEITHO trial), Cleveland Clinic (including for the ExCEED trial, funded by Edwards), Contego Medical (Chair, PERFORMANCE 2), Duke Clinical Research Institute, Mayo Clinic, Mount Sinai School of Medicine (for the ENVISAGE trial, funded by Daiichi Sankyo; for the ABILITY-DM trial, funded by Concept Medical), Novartis, Population Health Research Institute; Rutgers University (for the NIH-funded MINT Trial); Honoraria, American College of Cardiology (Senior Associate Editor, Clinical Trials and News, ACC.org; Chair, ACC Accreditation Oversight Committee), Arnold and Porter law firm (work related to Sanofi/Bristol-Myers Squibb clopidogrel litigation), Baim Institute for Clinical Research (formerly Harvard Clinical Research Institute; RE-DUAL PCI clinical trial steering committee funded by Boehringer Ingelheim; AEGIS-II executive committee funded by CSL Behring), Belvoir Publications (Editor-in-Chief, Harvard Heart Letter), Canadian Medical and Surgical Knowledge Translation Research Group (clinical trial steering committees), Cowen and Company, Duke Clinical Research Institute (clinical trial steering committees, including for the PRONOUNCE trial, funded by Ferring Pharmaceuticals), HMP Global (Editor-in-Chief, Journal of Invasive Cardiology), Journal of the American College of Cardiology (Guest Editor; Associate Editor), K2P (Co-Chair, interdisciplinary curriculum), Level Ex, Medtelligence/ReachMD (CME steering committees), MJH Life Sciences, Oakstone CME (Course Director, Comprehensive Review of Interventional Cardiology), Piper Sandler, Population Health Research Institute (for the COMPASS operations committee, publications committee, steering committee, and USA national co-leader, funded by Bayer), Slack Publications (Chief Medical Editor, Cardiology Today’s Intervention), Society of Cardiovascular Patient Care (Secretary/Treasurer), WebMD (CME steering committees), Wiley (steering committee); Other: Clinical Cardiology (Deputy Editor), NCDR-ACTION Registry Steering Committee (Chair), VA CART Research and Publications Committee (Chair); Patent, Sotagliflozin (named on a patent for sotagliflozin assigned to Brigham and Women’s Hospital assigned to Lexicon; neither I nor Brigham and Women’s Hospital receive any income from this patent); Research Funding, Abbott, Acesion Pharma, Afimmune, Aker Biomarine, Amarin, Amgen, AstraZeneca, Bayer, Beren, Boehringer Ingelheim, Boston Scientific, Bristol-Myers Squibb, Cardax, CellProthera, Cereno Scientific, Chiesi, CinCor, Cleerly, CSL Behring, Eisai, Ethicon, Faraday Pharmaceuticals, Ferring Pharmaceuticals, Forest Laboratories, Fractyl, Garmin, HLS Therapeutics, Idorsia, Ironwood, Ischemix, Janssen, Javelin, Lexicon, Lilly, Medtronic, Merck, Moderna, MyoKardia, NirvaMed, Novartis, Novo Nordisk, Owkin, Pfizer, PhaseBio, PLx Pharma, Recardio, Regeneron, Reid Hoffman Foundation, Roche, Sanofi, Stasys, Synaptic, The Medicines Company, Youngene, 89Bio; Royalties, Elsevier (Editor, Braunwald’s Heart Disease); Site Co-Investigator, Abbott, Biotronik, Boston Scientific, CSI, Endotronix, St. Jude Medical (now Abbott), Philips, SpectraWAVE, Svelte, Vascular Solutions; Trustee, American College of Cardiology; Unfunded Research, FlowCo, Takeda. Prof. Giuseppe Biondi-Zoccai has consulted for Cardionovum, CrannMedical, Innovheart, Meditrial, Opsens Medical, Replycare, Teleflex, and Terumo. All other authors report that they have no potential conflict of interest that might be relevant to the contents of this manuscript.

Figures

**Figure 1**
A patient with a strong family history of CAD, with cardiac CT positive for non-obstructive CAD on proximal LAD (panels A,B). A high-risk fibrolipidic plaque (red arrow) with positive remodeling, low attenuation, and small spotty calcification is evident in both the long (panel C) and short (panel D) axis views.

**Figure 2**
A case of a patient with a family history of sudden cardiac death, with frequent but isolated ectopic ventricular beats. Cardiac MRI was completely normal, with no evidence of myocardial fibrosis. (A). 4 Chamber view; (B). 2 Chamber view; (C). 3 Chamber view.

**Figure 3**
Global longitudinal strain (GLS) of the left ventricle in a patient after anterior ST-segment elevation myocardial infarction. Left ventricular ejection fraction was moderately reduced (40%) and the peak systolic GLS was −11.3%.

**Figure 4**
Global longitudinal strain (GLS) of the left ventricle in a patient after non-ST-elevation myocardial infarction revascularized with coronary artery bypass grafting. Left ventricular ejection fraction was preserved (56%) and the peak systolic GLS was −11.6%.

**Figure 5**
A patient with previous percutaneous revascularization of the right coronary artery, with cardiac CT showing evident in-stent restenosis in both long-axis view (panels A,B) and short-axis view (panels C–E). In panel (D), a clear hypodensity is evident inside the stent lumen compared with panels (C,E).

**Figure 6**
A case from a patient with a recent myocardial infarction. Cardiac MRI evidenced the presence of extensive myocardial left ventricular fibrosis associated with worse prognosis at follow-up.

See this image and copyright information in PMC

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Role of Cardiovascular Imaging in Risk Assessment: Recent Advances, Gaps in Evidence, and Future Directions

Affiliations

Role of Cardiovascular Imaging in Risk Assessment: Recent Advances, Gaps in Evidence, and Future Directions

Authors

Affiliations

Abstract

Conflict of interest statement

Figures

References

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