[Invasive angiography, computed tomography or magnetic resonance imaging for coronary imaging and cardiovascular risk stratification? Regulatory and practical considerations].

In 2003, risk stratification in coronary heart disease is routinely performed by the results of coronary angiogram, the invasive gold standard angiography. Combined with the left ventricular ejection fraction assessment, the classification in one, two or three vessel disease remain the cornerstone of the revascularization strategy despite well-known limitations of this approach. Invasive coronary angiography is a mature technic with recommendations for training program and guidelines for indications. By comparison, the new noninvasive coronary imaging tools, computed tomography (CT) and magnetic resonance (MR) imaging, are just emerging. Coronary artery MR angiography is one of the most challenging areas because of the size and topology of the coronary arteries, as well as cardiac and respiratory motion. Multidetector-row and multisclice spiral computed tomography appear of most value for the detection of coronary artery disease with an excellent negative predictive value for proximal and middle main branches. Together, MR and CT, provide unique information that may predict cardiovascular risk. They identify flow-limiting coronary stenoses and calcified plaques, directly image the atherosclerotic lesions, measure atherosclerotic burden and characterize plaque components. Nevertheless, invasive coronary angiography still remain the first step of percutaneous coronary intervention. Therefore, one of the ultimate goals for the clinicians is the identification of the high-risk patient through a combination of strategies such as assessment of conventional risk factors, blood markers, and imaging. Indifferently to the imaging tool, the treatment should consider a human being and not only a picture.