This is an editorial by Rumberger JA in JACC accompanying the article by Leber et al on the same subject, covered in an earlier post.
Rumberger dissects out the issues (the edges) that need to be sorted out before cardiac CT becomes a routine tool for plaque evaluation and characterization. These include
1. Spatial resolution - currently at 0.6x0.4x0.4. This needs to be further improved and needs to be made more isotropic.
2. Low density resolution - this needs further technical improvement with respect to the detectors, all of whom have some element of after-glow, which reduces low-density resolution
3. Temporal resolution - currently at around 183ms, this needs to be brought down to 50-100ms as with cardiac MRIs and EBCTs.
Rumberger postulates that maybe marrying EBCT technology to multi-detector technology might do this for us. He does not talk about the dual-CT, which currently is expected to bring down temporal resolution to at least 83ms or so and make cardiac CT non-heart rate dependent. Moreover with the use of the dual-source CT (Siemens Defintion - DSCT), hopefully, some of the issues with detection of calcified plaques as well as vessel analysis in the presence of calcified plaques may get sorted out.
Once we have such technology, it may be possible to evaluate further this large soft plaque that we see in this asymptomatic patient, who had one episode of atypical chest pain and came for a cardiac CT. This plaque straddles the D1 origin and produces no luminal narrowing. This is an example of marked positive remodelling, however no large lipid core could be identified. Obviously, the fibrous cap cannot be seen on CT currently.