What does the clinical cardiologist need from noninvasive cardiac imaging: is it time to adjust practices to meet evolving demands?

With the recent emergence of multidetector computed tomography angiography, coronary anatomy can now be assessed noninvasively. Until this advancement, functional noninvasive imaging used to serve as a gatekeeper that governed access to invasive diagnosis by coronary angiography and subsequent therapy. In the current era the threshold for access to coronary anatomy will be lowered. Functional noninvasive imaging will often come second, while anatomy is known already. If appropriate use of revascularization procedures is to be promoted, functional evaluation shall play an even greater role than before as a guide for selection of therapy. In subjects screened while the atherosclerotic disease is still at a preclinical stage, the ability to image plaque activity in the absence of flow-limiting stenosis will be essential in our attempts to prevent sudden ischemic cardiac death and unheralded myocardial infarction. In patients with advanced age and extensive obstructive disease, the diagnostic performance of functional testing will have to be raised by shifting from "per-patient" to "per-vessel" accuracy. Reengineering of currently available methods or the development of novel technologies that provide an integrative evaluation of anatomy and function will be necessary. With the availability of an increasing number of imaging options, it is anticipated that the emphasis will be placed more than ever on cost-effectiveness on a population basis, as well as on segmental predictive accuracy in the individual subject.