C.P. Kaiser, Editor

For many areas in cardiovascular treatments, one product or protocol is generally tested against a similar or competing product or protocol. In imaging, however, the standard has been to test the imaging modality for its accuracy without follow-up to determine the test's impact on outcomes. That paradigm has shifted with the recent launch of the PROMISE trial, which will compare coronary CT angiography (CCTA) with functional stress testing, such as exercise ECG, stress echocardiography and stress nuclear imaging, in 10,000 low- to intermediate-risk patients.

"We haven't done large scale randomized controlled trials of different testing strategies before, though at least 10 million people in the U.S. are in this clinical situation," says Pamela Douglas, MD, principal investigator of PROMISE. Knowing how each test fares against the others will pave the way for more personalized triaging of patients to the most appropriate imaging test.

The trend is to match the modality with the patient and each diagnostic imaging modality has strengths in certain patient populations. A Spotlight session on April 3, titled "Proving Improved Patient Outcomes and Cost-Effectiveness of CV Imaging," will detail the strengths of echocardiography, MRI and nuclear medicine when used effectively to improve outcomes.

Cardiologists will certainly need to be prepared to answer questions on radiation risk of diagnostic imaging procedures, particularly after several high-profile radiation exposure cases involving brain perfusion CT scans. Also, radiation will be on the minds of patients as the nuclear plant disaster in Japan continues to unfold, with its concomitant downstream effects on everything from food to the atmosphere.

The good news is that the effective radiation dose from a cardiac CT scan can be as low as 1 to 5 mSv using well-known radiation reduction techniques. In addition, the radiation associated with SPECT MPI can be reduced using various techniques and technology.

It can be difficult talking about radiation exposure to patients, so a Spotlight Session on April 3 titled "Diagnostic Imaging Radiation: How Much of a Clinical Issue?" promises to help inform cardiologists on these issues.

The heart failure epidemic poses many challenges to cardiologists, and echo is the dominant workhorse imaging modality of choice for these patients. But as the once encompassing congestive heart failure umbrella is parsed into smaller groups with different needs and risks, other imaging modalities are finding their niche. MRI, CT and nuclear medicine each have something to offer these patients and cardiologists can learn about more on April 3 in a session titled "Imaging Challenges in CHF Answered by a Multimodality Approach."

Imaging in cardiology has taken on a bigger role than ever and it will all be covered ACC.11. Imaging for valves; advances in echo, MRI and CT; multimodality imaging and hybrid imaging; and imaging in the cath lab. As payors increasingly demand better outcomes, it becomes more important to understand the nuances associated with various imaging modalities and how best to fit them to particular patients.

The i2 Summit, which runs in conjunction with ACC.11, means "Innovation and Intervention." With a special focus on intervention, the i2 Summit rounds out the excellent educational sessions at ACC.11.

Optimal imaging in the cath lab, as well as before and after procedures, is central to improved outcomes. Various intravascular imaging techniques, such as intravascular ultrasound and optical coherence tomography, can help with stent implantation, as well as follow-up and with plaque characterization. These are increasingly important areas of research and clinical routine as proper stent placement, expansion and apposition has been shown to reduce stent thrombosi, and plaque characterization can inform a more aggressive therapy.

In conjunction with these intravascular imaging techniques is fractional flow reserve (FFR). This physiologic indication of whether a lesion is hemodynamically occlusive is gaining ground, but there are nuances to understand regarding its use in various patient populations and with various lesion types.

We will be on the scene in New Orleans for ACC.11 covering all the latest news and education sessions. So, be sure to check your inbox for our daily coverage.

C.P. Kaiser
Editor