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type=\u0022text\/css\u0022 rel=\u0022stylesheet\u0022 href=\u0022\/\/d282kpwvnogo5m.cloudfront.net\/sites\/default\/files\/cdn\/css\/http\/css_Xg7z6oCTVgud_Q0huYz9x9iiD5H_2YPSJ5z2ZViSWdY.css\u0022 media=\u0022all\u0022 \/\u003E\n\u003Clink rel=\u0027stylesheet\u0027 type=\u0027text\/css\u0027 href=\u0027\/sites\/all\/modules\/contrib\/panels\/plugins\/layouts\/onecol\/onecol.css\u0027 \/\u003E\u003C\/head\u003E\u003Cbody\u003E\u003Cdiv class=\u0022panels-ajax-tab-panel panels-ajax-tab-panel-sageoa-tab-art\u0022\u003E\u003Cdiv class=\u0022panel-display panel-1col clearfix\u0022 \u003E\n  \u003Cdiv class=\u0022panel-panel panel-col\u0022\u003E\n    \u003Cdiv\u003E\u003Cdiv class=\u0022panel-pane pane-highwire-markup\u0022 \u003E\n  \n      \n  \n  \u003Cdiv class=\u0022pane-content\u0022\u003E\n    \u003Cdiv class=\u0022highwire-markup\u0022\u003E\u003Cdiv xmlns=\u0022http:\/\/www.w3.org\/1999\/xhtml\u0022 id=\u0022content-block-markup\u0022 xmlns:xhtml=\u0022http:\/\/www.w3.org\/1999\/xhtml\u0022\u003E\u003Cdiv class=\u0022article fulltext-view \u0022\u003E\u003Cspan class=\u0022highwire-journal-article-marker-start\u0022\u003E\u003C\/span\u003E\u003Cdiv class=\u0022section abstract\u0022 id=\u0022abstract-1\u0022\u003E\u003Ch2\u003ESummary\u003C\/h2\u003E\n            \u003Cp id=\u0022p-1\u0022\u003EThis article discusses the future of cardiac imaging: changes that favor the use of echocardiography (ECHO), important indications for non-invasive imaging (the ability to provide a work-up of new onset heart failure and chest pain, risk stratification in suspected CAD, and assessment of myocardial viability), the benefits of sequential imaging for diagnosing ischemic heart disease, and current challenges in imaging.\u003C\/p\u003E\n         \u003C\/div\u003E\u003Cul class=\u0022kwd-group\u0022\u003E\u003Cli class=\u0022kwd\u0022\u003Ecardiac imaging techniques\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003Eimaging modalities\u003C\/li\u003E\u003C\/ul\u003E\u003Cdiv class=\u0022section\u0022 id=\u0022sec-1\u0022\u003E\n         \n         \u003Cdiv id=\u0022F1\u0022 class=\u0022fig pos-float  odd\u0022\u003E\u003Cdiv class=\u0022highwire-figure\u0022\u003E\u003Cdiv class=\u0022fig-inline-img-wrapper\u0022\u003E\u003Cdiv class=\u0022fig-inline-img\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/8\/6\/5\/F1.large.jpg?width=800\u0026amp;height=600\u0026amp;carousel=1\u0022 title=\u0022\u0022 class=\u0022fragment-images colorbox-load\u0022 rel=\u0022gallery-fragment-images-248337226\u0022 data-figure-caption=\u0022\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003E\u003Cimg class=\u0022fragment-image\u0022 alt=\u0022Figure1\u0022 src=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/8\/6\/5\/F1.medium.gif\u0022\/\u003E\u003C\/a\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cul class=\u0022highwire-figure-links inline\u0022\u003E\u003Cli class=\u00220 first\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/8\/6\/5\/F1.large.jpg?download=true\u0022 class=\u0022highwire-figure-link highwire-figure-link-download\u0022 title=\u0022Download Figure1\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload figure\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00221\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/8\/6\/5\/F1.large.jpg\u0022 class=\u0022highwire-figure-link highwire-figure-link-newtab\u0022 target=\u0022_blank\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EOpen in new tab\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00222 last\u0022\u003E\u003Ca href=\u0022\/highwire\/powerpoint\/11131\u0022 class=\u0022highwire-figure-link highwire-figure-link-ppt\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload powerpoint\u003C\/a\u003E\u003C\/li\u003E\u003C\/ul\u003E\u003C\/div\u003E\u003C\/div\u003E\n         \u003Cp id=\u0022p-2\u0022\u003EThomas H. Marwick, PhD, Princess Alexandra Hospital, Brisbane, Australia, discussed changes that favor the use of echocardiography (ECHO).\u003C\/p\u003E\n         \u003Cp id=\u0022p-3\u0022\u003EEasier to use, handheld ECHO devices that are appropriate for office and bedside diagnoses, already have proven to be useful in providing additional diagnostic and prognostic information in the examination of patients who have a low likelihood of myocardial ischemia or infarction and symptoms that are suggestive of acute coronary syndrome [Weston P et al. \u003Cem\u003EAm Heart Journal\u003C\/em\u003E 2004]. However, better training guidelines, competency evaluation, and adoption of a uniform method for computer quantification of myocardial imaging are needed if these devices are to be used by non-echocardiographers for clinical decision-making [De Cara J et al. \u003Cem\u003EEur J Echo\u003C\/em\u003E 2003].\u003C\/p\u003E\n         \u003Cp id=\u0022p-4\u0022\u003EAs a diagnostic tool, ECHO faces some challenges, which may be overcome through technological development. Two-dimensional strain (novel software for real-time quantitative ECHO assessment of myocardial function) may reduce subjectivity, address the need to identify cardiac problems earlier, and resolve some training issues [Leitman M et al. \u003Cem\u003EJ Am Soc Echocardiogr\u003C\/em\u003E 2004]. High frame rate 3D imaging should improve the accuracy and reproducibility of quantitative ECHO measurements and the success rate of early diagnoses.\u003C\/p\u003E\n         \u003Cp id=\u0022p-5\u0022\u003EThere also is good evidence that real-time contrast improves sensitivity of dobutamine stress echocardiography and may provide incremental prognostic information for patients with known or suspected coronary artery disease (CAD) [Tsutsui JM et al. \u003Cem\u003ECirculation\u003C\/em\u003E 2005]. Experiments are ongoing using microbubbles in contrast agents. Microbubbles that are cavitated with ultrasonography can be used to dissolve blood clots or deliver drugs [Unger EC et al. \u003Cem\u003EEur J Radiol\u003C\/em\u003E 2002].\u003C\/p\u003E\n         \u003Cp id=\u0022p-6\u0022\u003EThe meshing of automation, minimization, and 3D imaging will ensure the expanding use of ECHO, Dr. Marwick concluded.\u003C\/p\u003E\n         \u003Cp id=\u0022p-7\u0022\u003EHeiko Mahrholdt, MD, Robert-Bosch Krankenhaus, Stuttgart, Germany, noted that important indications for non-invasive imaging include the ability to provide a work-up of new onset heart failure and chest pain, risk stratification in suspected CAD, and assessment of myocardial viability. Cardiac magnetic resonance (CMR) provides the ultimate one-stop diagnostic evaluation and can provide information that concerns morphology, function, valvular assessment, myocardial perfusion, and non-invasive tissue characterization based on detection of myocardial edema, necrosis, and scarring. In severe ischemic heart failure, CMR identifies areas of decreased flow, metabolism, and myocardial edema, as well as PET, but identifies scar tissue more frequently [Cury RC et al. \u003Cem\u003ECirculation\u003C\/em\u003E 2008].\u003C\/p\u003E\n         \u003Cp id=\u0022p-8\u0022\u003ECMR has higher spatial resolution than single photon emission computed tomography (SPECT) and can detect subendocardial infarcts that SPECT misses [Wagner A et al. \u003Cem\u003ELancet\u003C\/em\u003E 2003]. CMR can be used to distinguish between reversible and irreversible myocardial ischemic injury, predict improvement after revascularization [Kim RJ et al. \u003Cem\u003EN Engl J Med\u003C\/em\u003E 2000], and has the best reproducibility of all non-invasive imaging techniques [Mahrholdt H et al. \u003Cem\u003ECirculation\u003C\/em\u003E 2002] (\u003Ca id=\u0022xref-fig-2-1\u0022 class=\u0022xref-fig\u0022 href=\u0022#F2\u0022\u003EFigure 1\u003C\/a\u003E).\u003C\/p\u003E\n         \u003Cdiv id=\u0022F2\u0022 class=\u0022fig pos-float  odd\u0022\u003E\u003Cdiv class=\u0022highwire-figure\u0022\u003E\u003Cdiv class=\u0022fig-inline-img-wrapper\u0022\u003E\u003Cdiv class=\u0022fig-inline-img\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/8\/6\/5\/F2.large.jpg?width=800\u0026amp;height=600\u0026amp;carousel=1\u0022 title=\u0022Relation Between the Transmural Extent of Hyperenhancement Before Revascularization and the Likelihood of Increased Contractility After Revascularization.\u0022 class=\u0022fragment-images colorbox-load\u0022 rel=\u0022gallery-fragment-images-248337226\u0022 data-figure-caption=\u0022Relation Between the Transmural Extent of Hyperenhancement Before Revascularization and the Likelihood of Increased Contractility After Revascularization.\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003E\u003Cimg class=\u0022fragment-image\u0022 alt=\u0022Figure 1.\u0022 src=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/8\/6\/5\/F2.medium.gif\u0022\/\u003E\u003C\/a\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cul class=\u0022highwire-figure-links inline\u0022\u003E\u003Cli class=\u00220 first\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/8\/6\/5\/F2.large.jpg?download=true\u0022 class=\u0022highwire-figure-link highwire-figure-link-download\u0022 title=\u0022Download Figure 1.\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload figure\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00221\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/8\/6\/5\/F2.large.jpg\u0022 class=\u0022highwire-figure-link highwire-figure-link-newtab\u0022 target=\u0022_blank\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EOpen in new tab\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00222 last\u0022\u003E\u003Ca href=\u0022\/highwire\/powerpoint\/11134\u0022 class=\u0022highwire-figure-link highwire-figure-link-ppt\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload powerpoint\u003C\/a\u003E\u003C\/li\u003E\u003C\/ul\u003E\u003C\/div\u003E\u003Cdiv class=\u0022fig-caption\u0022 xmlns:xhtml=\u0022http:\/\/www.w3.org\/1999\/xhtml\u0022\u003E\u003Cspan class=\u0022fig-label\u0022\u003EFigure 1.\u003C\/span\u003E \n               \u003Cp id=\u0022p-9\u0022 class=\u0022first-child\u0022\u003ERelation Between the Transmural Extent of Hyperenhancement Before Revascularization and the Likelihood of Increased Contractility After Revascularization.\u003C\/p\u003E\n            \u003Cdiv class=\u0022sb-div caption-clear\u0022\u003E\u003C\/div\u003E\u003C\/div\u003E\u003C\/div\u003E\n         \u003Cp id=\u0022p-10\u0022\u003ECMR could replace SPECT in many trials that use \u201cinfarct size\u201d as an endpoint. The combination of cine, contrast, and perfusion CMR has the potential to overcome many limitations (sensitivity, specificity and accuracy) of other techniques that currently are used in clinical settings and emergency rooms, although the limited availability and costs of CMR remain challenges (\u003Ca id=\u0022xref-table-wrap-1-1\u0022 class=\u0022xref-table\u0022 href=\u0022#T1\u0022\u003ETable 1\u003C\/a\u003E).\u003C\/p\u003E\n         \u003Cdiv id=\u0022T1\u0022 class=\u0022table pos-float\u0022\u003E\u003Cdiv class=\u0022table-inline\u0022\u003E\u003Cdiv class=\u0022callout\u0022\u003E\u003Cspan\u003EView this table:\u003C\/span\u003E\u003Cul class=\u0022callout-links\u0022\u003E\u003Cli class=\u00220 first\u0022\u003E\u003Ca href=\u0022\/\u0022 class=\u0022table-expand-inline\u0022 data-table-url=\u0022\/highwire\/markup\/11137\/expansion?postprocessors=highwire_figures%2Chighwire_math%2Chighwire_inline_linked_media%2Chighwire_embed\u0026amp;table-expand-inline=1\u0022 html=\u00221\u0022 fragment=\u0022#\u0022 external=\u00221\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EView inline\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00221\u0022\u003E\u003Ca href=\u0022\/highwire\/markup\/11137\/expansion?width=1000\u0026amp;height=500\u0026amp;iframe=true\u0026amp;postprocessors=highwire_figures%2Chighwire_math%2Chighwire_inline_linked_media\u0022 class=\u0022colorbox colorbox-load table-expand-popup\u0022 rel=\u0022gallery-fragment-tables\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EView popup\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00222 last\u0022\u003E\u003Ca href=\u0022\/highwire\/powerpoint\/11137\u0022 class=\u0022highwire-figure-link highwire-figure-link-ppt\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload powerpoint\u003C\/a\u003E\u003C\/li\u003E\u003C\/ul\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cdiv class=\u0022table-caption\u0022\u003E\u003Cspan class=\u0022table-label\u0022\u003ETable 1.\u003C\/span\u003E \n               \u003Cp id=\u0022p-11\u0022 class=\u0022first-child\u0022\u003EComparison to Other Techniques.\u003C\/p\u003E\n            \u003Cdiv class=\u0022sb-div caption-clear\u0022\u003E\u003C\/div\u003E\u003C\/div\u003E\u003C\/div\u003E\n         \u003Cp id=\u0022p-13\u0022\u003EHowever, Prof. Mahrholdt concluded, although CMR may address questions that are not answered by ECHO, ECHO will remain the first-line imaging method that is used at the bedside in 2020, and the use of SPECT, coronary CT, and diagnostic coronary angiograms will decrease. Frank M. Bengel, MD, Johns Hopkins Medical Institutions, Baltimore, MD, outlined the challenges for cardiac imaging starting from the belief that current imaging markers are not sufficient to meet the diagnostic needs of cardiovascular medicine in the future. He sees the need for imaging technologies that can detect the earliest stages of CAD in order to reverse or prevent disease progression, characterize disease on a more individual basis, monitor therapeutic intervention, and predict outcome. Although a number of technologies can image the myocardial disease process at the tissue, pathophysiologcal and morphological level, experimental studies have shown the feasibility of doing this at the molecular level, utilizing different cardiac molecular imaging targets.\u003C\/p\u003E\n         \u003Cp id=\u0022p-14\u0022\u003EThe integrins, a family of transmembrane receptor proteins that are composed of alpha and beta chains of heterodimeric adhesion molecules and found on almost all cell types, are involved in thrombus formation, matrix activation, inflammation and angiogenesis.\u003C\/p\u003E\n         \u003Cp id=\u0022p-15\u0022\u003EAn \u003Cem\u003Ein vivo\u003C\/em\u003E PET imaging approach that uses an \u003Csup\u003E18\u003C\/sup\u003EF-labeled alpha\u003Csub\u003Ev\u003C\/sub\u003Ebeta\u003Csub\u003E3\u003C\/sub\u003E integrin antagonist (\u003Csup\u003E18\u003C\/sup\u003EF-Galacto-RGD) to monitor integrin expression after myocardial infarction appears to hold promise for monitoring the post-ischemic myocardial repair processes [Higuchi T et al. \u003Cem\u003ECardiovasc Res\u003C\/em\u003E 2008]. The AT\u003Csub\u003E1\u003C\/sub\u003E radioligand receptor (AT\u003Csub\u003E1\u003C\/sub\u003ER), which mediates mitogenic, proinflammatory, proapoptotic, and profibrotic processes in stress conditions, also may be a target for molecular imaging in the heart [Zober TG et al. \u003Cem\u003ENucl Biol\u003C\/em\u003E 2006].\u003C\/p\u003E\n         \u003Cp id=\u0022p-16\u0022\u003ESeveral approaches that are aimed at identifying plaque inflammation, apoptosis, smooth muscle cell proliferation, extracellular matrix activation, oxidative stress, or platelet binding are being studied. For example, simvastatin has been shown to attenuate plaque inflammation as detected by \u003Csup\u003E18\u003C\/sup\u003EF-fluorodeoxyglucose positron emission tomography (\u003Csup\u003E18\u003C\/sup\u003EFDG-PET), coregistered with computerized tomography [Tahara N et al. \u003Cem\u003EJ Am Col Cardiol\u003C\/em\u003E 2006].\u003C\/p\u003E\n         \u003Cp id=\u0022p-17\u0022\u003EMolecular imaging approaches are fast emerging for identification of biologic targets that are associated with early disease that will be useful as a guide to treatment that is based on individual biology. To make molecular imaging a reality in 2020 there is a need for a successful translation of these experimental techniques to the clinic, multi-disciplinary collaboration, and the integration of molecular medicine and therapy efforts. \u201cIncreasing specificity of therapeutic and preventive measures requires increasing specificity of diagnostic tools,\u201d concluded Dr. Bengel.\u003C\/p\u003E\n         \u003Cp id=\u0022p-18\u0022\u003EFrank E. Rademakers, MD, Catholic University, Leuven, Belgium, discussed the benefits of using sequential imaging techniques for diagnoses of ischemic heart disease. \u201cWe need to focus on what we need to do, rather than on what we can do,\u201d he said. \u201cWe already know that if we can identify myocardial ischemia in a large territory and treat it using percutaneous coronary intervention or surgery early enough, the long-term risk of a major cardiac event can be reduced.\u201d\u003C\/p\u003E\n         \u003Cp id=\u0022p-19\u0022\u003ESince the 1980\u2032s, there has been an increase in the use of invasive cardiology and ECHO, little change in the use of stress and nuclear testing, and a decrease in the use of Swan-Ganz catheterization [Pearte CA et al. \u003Cem\u003EAm J Cardiol\u003C\/em\u003E 2008]. There are many potential imaging combinations, eg, CT or MRI with SPECT, PET, and ECHO. He advises demonstrating the benefits of first combining the measurements of these devices before combining the machines, as new techniques are not always helpful to the patient. A number of studies that use new imaging tools show suboptimal results, or predictability, and overlap as to predictive value.\u003C\/p\u003E\n         \u003Cp id=\u0022p-20\u0022\u003EThe use of diagnostic and prognostic tools should be balanced by each patient\u0027s circumstances, age, and expectations, while taking into consideration the risks, benefits, costs, and effectiveness of the procedure. Functional noninvasive imaging that uses a combination of approaches will play an even greater role as an imaging tool, and techniques that use ionizing radiations will be even more limited in the future. The use of stress cardiac MRI will emerge as an important noninvasive method in the detection of CAD, he concluded.\u003C\/p\u003E\n      \u003C\/div\u003E\u003Cul class=\u0022copyright-statement\u0022\u003E\u003Cli class=\u0022fn\u0022 id=\u0022copyright-statement-1\u0022\u003E\u00a9 2008 MD Conference Express\u003C\/li\u003E\u003C\/ul\u003E\u003Cspan class=\u0022highwire-journal-article-marker-end\u0022\u003E\u003C\/span\u003E\u003C\/div\u003E\u003Cspan id=\u0022related-urls\u0022\u003E\u003C\/span\u003E\u003C\/div\u003E\u003Ca href=\u0022http:\/\/mdc.sagepub.com\/content\/8\/6\/5.abstract\u0022 class=\u0022hw-link hw-link-article-abstract\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EView Summary\u003C\/a\u003E\u003C\/div\u003E  \u003C\/div\u003E\n\n  \n  \u003C\/div\u003E\n\u003C\/div\u003E\n  \u003C\/div\u003E\n\u003C\/div\u003E\n\u003C\/div\u003E\u003Cscript type=\u0022text\/javascript\u0022 src=\u0022http:\/\/mdc.sagepub.com\/sites\/all\/modules\/highwire\/highwire\/plugins\/highwire_markup_process\/js\/highwire_figures.js?nzmcjp\u0022\u003E\u003C\/script\u003E\n\u003Cscript type=\u0022text\/javascript\u0022 src=\u0022http:\/\/mdc.sagepub.com\/sites\/all\/modules\/highwire\/highwire\/plugins\/highwire_markup_process\/js\/highwire_openurl.js?nzmcjp\u0022\u003E\u003C\/script\u003E\n\u003Cscript type=\u0022text\/javascript\u0022 src=\u0022http:\/\/mdc.sagepub.com\/sites\/all\/modules\/highwire\/highwire\/plugins\/highwire_markup_process\/js\/highwire_tables.js?nzmcjp\u0022\u003E\u003C\/script\u003E\n\u003C\/body\u003E\u003C\/html\u003E"}