Dovetailing Intra-coronary Imaging and Physiology … the True Gold Standard

CoronaryChronic coronary disease and resultant chest pain can often be treated with medical therapies to minimise symptoms and improve quality of life.However, the case presented by Volleberg et al. highlights the intrinsic complexities of assessing and treating coronary artery disease in those with intrusive symptoms and failed medical therapy. 1 The case provides several insights that reaffirm the importance of using both intra-coronary physiology and imaging in the setting of coronary artery disease.A physiological assessment provides insight into where within the coronary vasculature symptoms may be emanating from.Physiology assessment also indicates whether the chest pain is because of a combination of epicardial coronary disease, and/or microcirculatory or endothelial dysfunction (identified by the adjunctive use of intra-coronary acetylcholine-provoking symptoms and clinical features consistent with coronary vasospasm).Whereas intra-coronary imaging such as highdefinition intravascular ultrasound (IVUS) or optical coherence tomography (OCT) provides unique lesion and vessel morphological information additive to generic angiographic assessment alone.The higher resolution imaging afforded by OCT specifically enables more detailed evaluation than IVUS at the endoluminal level and for the superficial plaque (e.g. in detecting cavity formation of a plaque rupture, thin-cap fibroatheroma and stent architecture).Moreover, OCT also provides higher fidelity identification of sub-optimal percutaneous coronary intervention (PCI) or complications from PCI, such as coronary dissections, tissue protrusions, stent under expansion and malapposition. 2 OCT specifically can evaluate neointimal proliferation, neoatherosclerosis, uncovered struts, and persistent/late-acquired stent malapposition, which may be associated with adverse events.