What role for cardiac imaging in chronic coronary syndromes: review of the literature in light of the latest recommendations

The 2019 ESC guidelines redefined stable coronary artery disease as chronic coronary syndrome, highlighting the dynamic nature of coronary artery disease. This condition is characterized by the gradual accumulation of atherosclerotic plaques in the epicardial coronary arteries. Chronic coronary syndrome can result in myocardial ischemia due to supply–demand mismatch, often triggered by physical or emotional stress. The clinical course may be abruptly interrupted by plaque rupture or erosion, leading to acute coronary syndromes. Revolutionary advances in non-invasive imaging have transformed chronic coronary syndrome diagnosis algorithm and management. Coronary computed tomography angiography provides detailed anatomical insights, identifying high-risk plaques with features like low attenuation and positive remodeling, as evidenced by SCOT-HEART, which reported reduced coronary events (HR: 0.59, p=0.004). Stress echocardiography may detect ischemia-induced wall motion abnormalities (sensitivity 85-95%), while cardiovascular magnetic resonance is paramount in functional assessment, offering 81-86% sensitivity/specificity and detecting microvascular dysfunction via perfusion and late gadolinium enhancement (LGE). Nuclear imaging (SPECT/PET) enhances ischemia detection, with PET’s myocardial flow reserve (MFR) improving prognostic accuracy (sensitivity 90%, specificity 88%). AI-driven innovations, such as CT-derived fractional flow reserve automate plaque quantification and may reduce in the future unnecessary invasive angiographies by 19-25% (p=0.01), while dynamic CT myocardial perfusion integrates anatomical and hemodynamic data, boosting diagnostic accuracy (87%). These advancements enable precise risk stratification and more tailored therapeutic strategies. Tailored multimodal imaging, based on pre-test likelihood and patient characteristics, improves the management and prognostic of chronic coronary syndrome.