The identification of intracoronary thrombus and atherothrombosis is central to the diagnosis of acute myocardial infarction, with the differentiation between type 1 and type 2 myocardial infarction being crucial for immediate patient management. Invasive coronary angiography has remained the principal imaging modality used in the investigation of patients with myocardial infarction. More recently developed invasive intravascular imaging approaches, such as angioscopy, intravascular ultrasound and optical coherence tomography, can be used as adjunctive imaging modalities to provide more direct visualisation of coronary atheroma and the causes of myocardial infarction as well as to improve the sensitivity of thrombus detection. However, these invasive approaches have practical and logistic constraints that limit their widespread and routine application. Non-invasive angiographic techniques, such as CT and MRI, have become more widely available and have improved the non-invasive visualisation of coronary artery disease. Although they also have a limited ability to reliably identify intracoronary thrombus, this can be overcome by combining their anatomical and structural characterisation of coronary anatomy with positron emission tomography. Specific radiotracers which bind with high specificity and sensitivity to components of thrombus, such as activated platelets, fibrin and factor XIIIa, hold promise for the non-invasive detection of intracoronary thrombus. The development of these novel non-invasive approaches has the potential to inform clinical decision making and patient management as well as to provide a non-invasive technique to assess the efficacy of novel antithrombotic therapies or interventional strategies. However, these have yet to be realised in routine clinical practice.
- myocardial infarction
- positron emission tomography computed tomography
- coronary angiography
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Contributors BW drafted the manuscript, which was critically reviewed by DEN, MCW, MRD and ET. All authors approved the final submission.
Funding BW (FS/CRTF/21/24129), ET (FS/CRTF/20/24086), MCW (FS/ICRF/20/26002, FS/11/014, CH/09/002) DEN (CH/09/002, RG/16/10/32375, RE/18/5/34216) and MRD (FS/14/78/31020) are supported by the British Heart Foundation. DEN is the recipient of a Welcome Trust Senior Investigator Award (WT103782AIA). MRD is supported by the Sir Jules Thorn Biomedical Research Award 2015 (15/JTA). MCW is supported by The Chief Scientist Office of the Scottish Government Health (PCL/17/04) and Academy of Medical Sciences (SGL016/1059).
Competing interests MCW has given talks for Canon Medical Systems and Siemens Healthineers. MRD and DEN are on the Editorial Board for BMJ Heart.
Provenance and peer review Commissioned; externally peer reviewed.