Through the Looking Glass: Is There Still a Gold Standard in the Wonderland of Cardiac Imaging?

摘要

The diagnosis of myocardial ischemia, as a consequence of flow obstruction within the coronary arterial distribution (ie, angina pectoris), has always has been a clinical diagnosis. It is based on a patient's history of retrosternal, squeezing, pressure-like pain or discomfort, which is reliably precipitated by exertion and reliably relieved by rest, and it is irrelevant to the diagnosis whether the patient is 5 years old or 95 years old. To be sure, a 5-year-old with myocardial ischemia causing angina pectoris most likely has congenital coronary artery anomalies. Conversely, in adults, angina pectoris is most commonly associated with intraluminal obstructive atherosclerotic coronary artery disease. Of utmost clinical importance, however, in the absence of symptoms to suggest the presence of unstable angina pectoris or the presence of stress myocardial perfusion imaging techniques demonstrating a significant burden of ischemia, the simple anatomic demonstration of coronary atherosclerosis has never been a sufficient criterion to mandate the need for invasive revasculariza-tion. Thus, vascular function usually trumps vascular form. And yet despite this clinical reality, the wonderland of primarily anatomically-based vascular imaging techniques, intended to more easily or more accurately facilitate the diagnosis of atherosclerotic coronary artery disease, continues to rapidly evolve.