Outcomes of anatomical versus functional testing for coronary artery disease

Temporal Trends in Noninvasive and Invasive Cardiac Testing From 2010 to 2022 in the US Medicare Population

BACKGROUND

Cardiac diagnostic testing continues to evolve, and controversies remain regarding the optimal utilization of different procedures. We sought to evaluate changes in long-term utilization trends for a wide range of cardiac diagnostic tests in the context of advancing technologies and updated guidelines.

METHODS

Annual cardiac testing volumes from 2010 to 2022 in the Medicare Part B population were compared across tests and by provider specialty and analyzed using Joinpoint regression.

RESULTS

The most-utilized test in the Medicare population remained transthoracic echocardiography, accounting for 61.5% of cardiac testing use in 2011 and 67.7% in 2022, followed by single-photon emission computed tomography (CT) myocardial perfusion imaging, which decreased from 20.8% to 12.9%. Single-photon emission CT myocardial perfusion imaging use decreased relative to positron emission tomography myocardial perfusion imaging (ratio of 39:1 in 2011 to 7:1 in 2022), stress cardiac magnetic resonance (1179:1 in 2011, 268:1 in 2022), and coronary CT angiography (61:1 in 2011, 10:1 in 2022). Decreased use was also observed for exercise treadmill testing (2.3% to 1.7%), stress echocardiography (3.6% to 2.6%), multigated acquisition (0.4% to 0.1%), and invasive coronary angiography (8.0% to 7.0%). The use of fractional flow reserve by CT per 100 000 Medicare enrollees increased by >16-fold from 2018 (the first year covered) to 2022, and cardiac amyloidosis pyrophosphate scintigraphy studies increased 4-fold from 2011 to 2022 (0.17% to 0.68%). Positron emission tomography myocardial perfusion imaging volumes have surpassed exercise treadmill test volumes and, assuming the current rate of change continues, are projected to surpass stress echocardiography volumes in 2024. Coronary CT angiography is projected to overtake exercise treadmill testing in 2024 and stress echocardiography in 2025.

CONCLUSIONS

Between 2010 and 2022, cardiac diagnostic testing in the US Medicare population shifted from invasive angiography and traditional stress testing toward an increase in cardiac CT, cardiac magnetic resonance, and positron emission tomography. Pyrophosphate scintigraphy studies also increased, as did fractional flow reserve by CT since its introduction. Changes in preferred diagnostic modalities suggest a need to reevaluate current recommendations for training in cardiovascular medicine.

Review and Key Takeaways of the 2021 Percutaneous Coronary Intervention Guidelines

The 2021 Percutaneous Coronary Intervention guidelines completed by American College of Cardiology/American Heart Association/Society for Cardiovascular Angiography and Interventions provide a set of guidelines regarding revascularization strategies. With emphasis on equity of care, multidisciplinary heart team use, revascularization for acute coronary syndrome, and stable ischemic heart disease, the guidelines create a thorough framework with recommendations regarding therapeutic strategies. In this comprehensive review, our aim is to summarize the 2021 revascularization guidelines and analyze key points regarding each recommendation.

QUIET WARRIOR - Rationale and design: An ancillary study to the Women's IschemiA TRial to Reduce Events in Nonobstructive CAD (WARRIOR)

Background

Cardiovascular disease is the leading cause of death among women in the US, predominantly due to ischemic heart disease (IHD). There is a notable deficiency in therapies tailored for IHD in women, who often present with variable symptoms that delay diagnosis and treatment. In many cases, coronary angiography does not reveal obstructive coronary artery disease (CAD) despite increased risk for major adverse cardiac events (MACE) compared with sex and age-matched asymptomatic cohorts.

Objectives

The Women's IschemiA TRial to Reduce Events in Nonobstructive CAD (WARRIOR) evaluates intensive medical treatment for women with Ischemia with No Obstructive Coronary Arteries (INOCA). The QUIET WARRIOR sub-study aims to improve predictive tools for adverse outcomes by detailed analysis of Coronary Computed Tomography Angiography (CCTA) data and biorepository samples. These data will also uncover pathophysiological mechanisms associated with angina and MACE, improving predictive tools for symptomatic women with INOCA.

Methods

This ancillary study will analyze CCTA images from 600 WARRIOR subjects. It will assess clinical, social, and coronary artery variables, including plaque characteristics and markers of inflammation. Advanced imaging techniques and machine-learning models will be employed to quantify plaque features and predict clinical outcomes.

Expected results

The study aims to elucidate associations between CCTA-derived plaque characteristics, ischemic symptoms, and MACE. Anticipated findings include correlations of specific plaque attributes with angina severity and novel insights into inflammatory markers. Socioeconomic variables will also be examined for their impact on cardiovascular risk.

Conclusion

The QUIET WARRIOR sub-study will advance the understanding of INOCA in women, integrating clinical, imaging, and socioeconomic data to enhance risk prediction and guide personalized therapeutic strategies. This research will address critical gaps in managing nonobstructive CAD, promoting more equitable cardiovascular care.

Evaluation of the clinical value of CCTA as the preferred screening method in patients with chronic coronary syndrome

BACKGROUND

The advantages and disadvantages of direct invasive coronary angiography (ICA) and coronary computed tomographic angiography (CCTA) + ICA were compared in patients with suspected chronic coronary syndrome (CCS) who presented with angina symptoms or who had nonangina chest pain with abnormal electrocardiogram results.

METHODS

A total of 1200 patients who met the inclusion criteria at TEDA International Cardiovascular Hospital from January 2021 to December 2022 were randomly divided into two groups at a 1:1 ratio: the CCTA + ICA strategy (CCTA group) and the direct ICA strategy (ICA group). The baseline data were collected. All patients in the CCTA group underwent CCTA examination first. If these results showed positive obstructive coronary artery disease (CAD), then typical angina with coronary artery stenosis ranging from 50 to 70% or vascular segments could not be analysed due to severe calcification, so ICA was further performed for definitive diagnosis, and the ICA results were taken as the final diagnosis. All patients in the ICA group underwent ICA examination directly. Demographic data, cardiovascular risk factors, biochemical criteria, chest pain classification, coronary vessel lesion severity and drug use were compared between the two groups. All patients were followed for 1 year after discharge to observe major adverse cardiovascular events (MACE). The differences in unnecessary ICA rates, 1-year MACE rates, allergic reactions to contrast agents and hospitalization costs between the two groups were analysed. On the basis of the baseline clinical data of patients included in this study, a risk prediction model for obstructive CAD was established by logistic regression.

RESULTS

(1) There were 592 patients in the CCTA group and 594 patients in the ICA group. The percentage of unnecessary ICA procedures was 7.5% in the CCTA group and 55.2% in the ICA group (P < 0.001), which was a decrease of 86.4%. (2) Eighteen patients in the CCTA group were readmitted for severe angina, 4 of whom underwent unplanned percutaneous coronary intervention (PCI). Eight patients in the ICA group were readmitted for severe angina, 2 of whom underwent unplanned PCI. There were no cardiac deaths, nonfatal myocardial infarctions or strokes in either group over the 1-year follow-up. There was no statistically significant difference in the rate of MACE-free survival between the two groups (97.0% vs. 98.7%, log-rankχ²=1.996, P = 0.158). (3) Allergic reactions to contrast agent were observed in 28 patients in the CCTA group and 16 in the ICA group (P = 0.190). (4) The median hospitalization cost in the CCTA group was $1259.54, and that in the ICA group was $1399.41, which was a significant difference (P < 0.001) and a decrease of 9.99%. (5) Based on the combination of the logistic regression forward selection method and backward elimination method, variables with P < 0.05, including creatinine, age, physical activity-induced symptoms, hyperlipidaemia, diabetes and smoking history, were selected from the baseline data of patients to predict obstructive CAD. The above variables were used to establish a risk prediction model for obstructive CAD. The area under the ROC curve (AUC) of this model was 0.721, indicating good predictive ability.

CONCLUSION

In patients with suspected CCS, including typical angina, atypical angina and nonangina chest pain with abnormal electrocardiogram results, the use of CCTA as a first-line diagnostic test can reduce the unnecessary incidence of ICA and hospitalization costs without increasing the incidence of MACE. A risk prediction model of obstructive CAD was established on the basis of the baseline data of the patients enrolled in this study, providing a clinical basis for the decision to use CCTA or ICA. Patients with a low probability of obstructive CAD can be given priority for CCTA, whereas patients with a high probability can be given priority for ICA.

Non-invasive imaging assessment in angina with non-obstructive coronary arteries (ANOCA)

Due to its significant prevalence and clinical implications, angina with non-obstructive coronary arteries (ANOCA) has become a major focus in modern cardiology. In fact, diagnosing ANOCA presents a significant challenge. The final diagnosis is often difficult, delayed, and frequently necessitates an invasive assessment through coronary angiography. However, recent improvements in non-invasive cardiac imaging allow a diagnosis of ANOCA using a combination of clinical evaluation, anatomical coronary imaging, and functional testing. This narrative review aims to critically assess various non-invasive diagnostic methods and propose a multimodal approach to diagnose ANOCA and tailor appropriate treatments.

The prognostic value of preoperative CAD-RADS classification in patients undergoing isolated aortic valve surgery

To investigate the association between preoperative coronary artery disease (CAD) severity, as classified by the Coronary Artery Disease Reporting and Data System (CAD-RADS), and clinical outcomes in patients undergoing isolated aortic valve replacement (AVR). A total of 897 patients (452 women; mean age, 66.1 ± 9.3 years) who underwent isolated AVR and preoperative coronary computed tomography angiography (CCTA) between 2004 and 2022 were stratified by the CAD-RADS score. The outcomes of interest were all-cause death and major adverse cardiac and cerebrovascular events (MACCE). The CAD-RADS score was 0 in 290 (32%) patients, 1 in 208 (23%), 2 in 255 (29%), 3 in 82 (9%), and 4 in 62 (7%) patients. The rates of all-cause death and MACCE tended to increase in parallel with CAD-RADS score (4%, 10.5%, 8.2%, 18.2%, 28.1% at 5 years and 14.4%, 15.1%, 16.7%, 26.9%, 38.4% at 5 years, both P < 0.001). CAD-RADS score ≥ 3 was associated with a higher risk of all-cause death (HR 2.44, 95% CI: 1.52-3.93) and MACCE (HR 1.79, 95% CI: 1.27-2.52) after adjusting for potential confounders. Notably, patients with CAD-RADS ≥ 3 who received medical therapy in addition to coronary angiography (CAG) improved overall survival compared to those who did not undergo CAG. Preoperative CCTA with CAD-RADS assessment would be useful for screening concomitant CAD and predicting long-term clinical outcomes including all-cause death and MACCE in patients undergoing isolated AVR. For patients with CAD-RADS ≥ 3, it is essential to implement medicinal therapy or intervention along with CAG.

Diagnostic Performance and Clinical Impact of Photon-Counting Detector Computed Tomography in Coronary Artery Disease

BACKGROUND

Photon-counting detector-computed tomography (PCD-CT) has emerged as a promising technology, offering improved spatial resolution.

OBJECTIVES

This study aimed to evaluate the clinical impact and diagnostic performance of PCD-CT vs conventional energy-integrating detector computed tomography (EID-CT) for obstructive coronary artery disease (CAD).

METHODS

From 2022 to 2023, we retrospectively identified 7,833 consecutive patients who underwent clinically indicated coronary computed tomography angiography (CCTA) at a single center, with either PCD-CT (n = 3,876; NAEOTOM Alpha [Siemens Healthineers]) or EID-CT (n = 3,957; Revolution Apex 256 [GE HealthCare] or Aquilion ONE ViSION 320 [Canon Medical Systems]) scanners. Subsequent invasive coronary angiography (ICA) and percutaneous or surgical revascularization were performed as part of routine clinical care. Among those referred for ICA after coronary CTA, the presence of obstructive CAD in each vessel was determined by coronary CTA (severe stenosis on visual assessment per the Coronary Artery Disease Reporting and Data System) and ICA (≥50% diameter stenosis on quantitative coronary angiography) in a blinded fashion. The diagnostic performance of EID-CT and PCD-CT was compared by using quantitative coronary angiography as the reference standard.

RESULTS

Patients who underwent PCD-CT were less frequently referred to subsequent ICA than those undergoing EID-CT (9.9% vs 13.1%; P < 0.001). Among those who underwent ICA, revascularization was more frequently performed in the PCD-CT group than in the EID-CT group (43.4% vs 35.5%; P = 0.02). In the vessel-level analysis (n = 1,686), specificity (98.0% vs 93.0%; P < 0.001), positive predictive value (83.3% vs 63.0%; P = 0.002), and diagnostic accuracy (97.2% vs 92.8%; P < 0.001) were improved by PCD-CT. Sensitivity (90.9% vs 90.7%; P = 0.95) and negative predictive value (98.9% vs 98.7%; P = 0.83) for obstructive CAD were similar between the PCD-CT and EID-CT groups, respectively.

CONCLUSIONS

PCD-CT exhibited excellent diagnostic performance for detecting obstructive CAD. Compared with patients undergoing conventional EID-CT, fewer patients were referred to ICA after PCD-CT, but those referred were more likely to undergo revascularization.

Clinical risk prediction, coronary computed tomography angiography, and cardiovascular events in new-onset chest pain: the PROMISE and SCOT-HEART trials

BACKGROUND AND AIMS

Whether index testing using coronary computed tomography angiography (CTA) improves outcomes in stable chest pain is debated. The risk factor weighted clinical likelihood (RF-CL) model provides likelihood estimation of obstructive coronary artery disease. This study investigated the prognostic effect of coronary CTA vs. usual care by RF-CL estimates.

METHODS

Large-scale studies randomized patients (N = 13 748) with stable chest pain to coronary CTA as part of the initial work-up in addition to or instead of usual care including functional testing. Patients were stratified according to RF-CL estimates [RF-CL: very-low (≤5%), low (>5%-15%), and moderate/high (>15%)]. The primary endpoint was myocardial infarction or death at 3 years.

RESULTS

The primary endpoint occurred in 313 (2.3%) patients. Event rates were similar in patients allocated to coronary CTA vs. usual care [risk difference (RD) 0.3%, hazard ratio (HR) 0.84 (95% CI 0.67-1.05)]. Overall, 33%, 44%, and 23% patients had very-low, low, and moderate/high RF-CL. Risk was similar in patients with very low and moderate/high RF-CL allocated to coronary CTA vs. usual care [very low: RD 0.3%, HR 1.27 (0.74-2.16); moderate/high: RD 0.5%, HR 0.88 (0.63-1.23)]. Conversely, patients with low RF-CL undergoing coronary CTA had lower event rates [RD 0.7%, HR 0.67 (95% CI 0.47-0.97)]. The number needed to test using coronary CTA to prevent one event within 3 years was 143.

CONCLUSIONS

Despite an overall good prognosis, low RF-CL patients have reduced risk of myocardial infarction or death when allocated to coronary CTA vs. usual care. Risk is similar in patients with very-low and moderate/high likelihood.

Quality of Life Outcomes With a Risk-Based Precision Testing Strategy Versus Usual Testing in Stable Patients With Suspected Coronary Disease: Results From the PRECISE Randomized Trial

BACKGROUND

The PRECISE (Prospective Randomized Trial of the Optimal Evaluation of Cardiac Symptoms and Revascularization) trial compared an investigational precision diagnostic testing strategy (n=1057) with usual testing (n=1046) in patients with stable chest pain and suspected coronary artery disease. Quality of life (QOL) outcomes were a prespecified secondary end point.

METHODS

We assessed QOL by structured interviews in all trial participants at baseline and 45 days, 6 months, and 12 months postrandomization. QOL assessments included angina-related QOL (19-item Seattle Angina Questionnaire [SAQ-19]), generic health status (EQ-5D), and a 4-item care satisfaction survey (at 45 days only). The prespecified primary comparison was the 6-month SAQ Summary score outcomes (scale, 0 to 100; higher scores indicate greater health status). QOL data collection rates were high, with 99% complete baseline SAQ scores and 86.5% complete at the 6-month primary comparison follow-up. All comparisons were made as randomized.

RESULTS

At baseline, mean SAQ Summary scores were 70.9 in the Precision Strategy group (n=1050) and 70.4 in the Usual Testing group (n=1042). By 6 months, mean SAQ Summary scores had improved to 89.9 in the Precision Strategy group and 89.2 in the Usual Testing group, with a mean adjusted difference of 0.8 (95% CI, -0.3 to 2.0). The SAQ component scores showed similar improvement from baseline in both groups and no statistically significant or clinically meaningful differences between the 2 groups at any follow-up time point. By 6 months, 66% of patients in both groups were chest pain-free. EQ-5D visual analog scores also improved from baseline and showed no difference between groups during follow-up. Care satisfaction scores were high and similar at 45 days.

CONCLUSIONS

In stable patients with symptoms suggesting coronary artery disease, angina-related and overall QOL improved substantially over the initial 6 months independent of the testing strategy assigned.

REGISTRATION

URL: https://www.clinicaltrials.gov; Unique identifier: NCT03702244.

Economic Outcomes With Precision Diagnostic Testing Versus Usual Testing in Stable Chest Pain: Results From the PRECISE Randomized Trial

BACKGROUND

The PRECISE (Prospective Randomized Trial of the Optimal Evaluation of Cardiac Symptoms and Revascularization) demonstrated that a precision diagnostic strategy reduced the primary composite of death, nonfatal myocardial infarction, or catheterization without obstructive coronary artery disease by 65% in patients with nonacute chest pain compared with usual testing. Medical cost was a prespecified secondary end point.

METHODS

PRECISE randomized 2103 patients between December 2018 and May 2021 to usual testing or a precision strategy that used deferred testing for the lowest risk patients (20%) and coronary computed tomographic angiography with selective computed tomography-derived fractional flow reserve for the remainder. Resource use consumption data were collected from all study participants and hospital cost data from US participants (n=1125) to estimate total medical costs. The primary and secondary economic outcomes were total costs at 12 months and at 45 days, respectively, from the US health care system perspective. The mean cost differences between the 2 strategies were reported by intention-to-treat.

RESULTS

At 45 days, total costs were similar between the precision strategy and usual testing (mean difference, $182 [95% CI, -$555 to $661]). By 12 months, percutaneous coronary intervention and coronary artery bypass surgery had been performed in 7.2% and 2.0% of precision strategy patients and 3.5% and 1.7% of usual testing patients, respectively. At 1 year, precision strategy costs were $5299 versus $4821 for usual testing (mean difference, $478 [95% CI, -$889 to $1437]; P=0.43). Precision care decreased mean per-patient diagnostic cost by 27% and increased mean per-patient revascularization costs by 67%.

CONCLUSIONS

In the PRECISE trial, the precision strategy, a risk-based approach endorsed by current clinical practice guidelines, improved the clinical efficiency of testing and had similar costs to usual testing at 45 days and a nonsignificant $478 cost difference at 1 year.

REGISTRATION

URL: https://www.clinicaltrials.gov; Unique identifier: NCT03702244.

Exercise electrocardiogram combined with cadmium zinc tellurium (CZT) cardiac-dedicated single photon emission computed tomography (SPECT) predicts coronary artery disease

AIM

Coronary artery disease (CAD) is a primary cause of mortality, prompting ongoing research into noninvasive diagnostic modalities. This study aimed to evaluate the diagnostic efficacy of exercise electrocardiography testing (EET) combined with cadmium zinc tellurium cardiac-dedicated single photon emission computed tomography (CZT-SPECT) imaging for CAD.

MATERIALS AND METHODS

CZT-SPECT and EET were examined in 124 patients aged 20-85 years, followed by coronary angiography to evaluate the sensitivity, specificity, positive predictive value, and negative predictive value of EET/CZT-SPECT alone and in combination. CAD was defined as the presence of > 50% stenosis at the time of coronary angiography.

RESULTS

The sensitivity of the EET test alone was 31.58%, the specificity was 80%, the positive predictive value (PPV) was 22.22%, and the negative predictive value (NPV) was 86.6%. The corresponding values of CZT-SPECT alone were 36.07%, 92.06%, 81.48% and 59.79%, respectively. The combined results showed that the sensitivity, specificity, PPV, and NPV were 60.00%, 90.57%, 54.55%, and 92.31%, respectively. In this study, the positive likelihood ratio (PLR) diagnosed with EET alone was 1.58, the PLR diagnosed with CZT-SPECT alone was 4.54, and the PLR diagnosed with combination was 6.36.

CONCLUSION

The combination of CZT-SPECT and EET showed significantly improved CAD diagnostic accuracy compared with either approach alone.

Coronary Artery Disease and Major Adverse Cardiovascular Events in People With Hepatic Steatosis at Low Atherosclerotic Cardiovascular Disease Risk

BACKGROUND

Hepatic steatosis (HS) and 10-year atherosclerotic cardiovascular disease (ASCVD) risk ≥ 7.5% are associated with increased risk for cardiovascular events.

AIM

To assess underlying coronary artery disease (CAD) and major adverse cardiovascular event (MACE) among those with and without HS at different ASCVD risk.

METHODS

We evaluated stable chest pain patients receiving coronary computed tomography (CT) in the PROMISE trial. HS and CAD endpoints were defined on coronary CT. MACE was defined as unstable angina, non-fatal myocardial infarction, and all-cause death. Multivariable Cox regression, adjusting for CAD characteristics, assessed the association of HS with MACE for ASCVD < 7.5%.

RESULTS

One thousand two hundred and four of 3702 (32.5%) patients were at ASCVD < 7.5% and 20.3% (244/1204) of them had HS. Individuals with HS were younger (54.3 ± 5.2 vs. 55.8 ± 5.2; p < 0.001), more often males (40.2% [98/244] vs. 27.1% [260/960]; p < 0.001), had more risk factors/person (2.06 ± 0.89 vs. 1.93 ± 0.91; p = 0.047). CAD characteristics were similar between HS vs. non-HS patients at ASCVD < 7.5% and ASCVD ≥ 7.5% (all p > 0.05). Patients with HS had greater MACE rate compared to non-HS patients (ASCVD < 7.5%: 3.75%[9/244] vs. 1.5% [14/960]; p = 0.027 and ASCVD ≥ 7.5%: 4.7% [33/696] vs. 3.1% [56/1802]; p = 0.043). In patients without HS, MACE rate was higher in the ASCVD ≥ 7.5% vs. < 7.5% (3.1% [56/1802] vs. 1.5% [14/960]; p = 0.011). In patients with HS, MACE rates were not significantly different between ASCVD ≥ 7.5% vs. < 7.5% (4.7% [33/696] vs. 3.7% [9/244]; p = 0.484). In ASCVD < 7.5%, HS predicted MACE (aHR:2.34, 95%CI:1.01-5.43; p = 0.048), independent of CAD characteristics.

CONCLUSIONS

Individuals with HS at ASCVD < 7.5% risk had similar CAD characteristics as patients without HS at < 7.5% ASCVD risk, yet experienced comparable MACE rates as those at ASCVD ≥ 7.5%.

Feasibility of on-site CT-FFR analysis on cardiac photon-counting CT in evaluation of hemodynamically significant stenosis in comparison to invasive catheter angiography

OBJECTIVES

Coronary CT angiography (CCTA) is an excellent tool in ruling out coronary artery disease (CAD) but tends to overestimate especially highly calcified plaques. To reduce diagnostic invasive catheter angiographies (ICA), current guidelines recommend CT-FFR to determine the hemodynamic significance of coronary artery stenosis. Photon-Counting Detector CT (PCCT) revolutionized CCTA and may improve CT-FFR analysis in guiding patients.

METHODS

In this single-center study, patients with obstructive CAD who underwent CCTA using PCCT and subsequent ICA were included. Delta CT-FFR was calculated by subtracting the CT-FFR values 1.8 cm before and after the stenosis, with a cut-off value of ≥0.06 indicating hemodynamic significance. Revascularization during ICA defined a stenosis as hemodynamically significant. Sensitivity, specificity, negative and positive predictive value, and diagnostic accuracy of Delta CT-FFR have been determined. Patients were followed up to evaluate the rate of major adverse cardiovascular events (MACE) 6 months after CCTA.

RESULTS

A total of 28 patients (3 female, median age 68 years) were enrolled in this study. Delta CT-FFR was pathological in all patients who underwent revascularization. No patients with normal Delta CT-FFR required stent placement. In 39.29 % of the cases, calculation of Delta CT-FFR could have prevented patients from undergoing unnecessary ICA. The positive predictive value of Delta CT-FFR for CAD RADS 4a was 66.7 %, negative predictive value 100 %, and diagnostic accuracy 74 %.

CONCLUSION

Delta CT-FFR analysis using PCCT offers a feasible tool in identifying hemodynamically significant coronary artery stenosis and can help to reduce purely diagnostic ICA.

[Guidelines of the European Society of Cardiology on chronic coronary syndrome from 2024]

The 2024 European Society of Cardiology (ESC) guidelines on chronic coronary syndrome comprehensively summarize the symptoms, diagnostics and treatment of coronary artery disease, excluding acute coronary syndromes. The processing always begins with an estimation of the clinical probability, which should include not only the symptom profile but also the number of cardiovascular risk factors and is further modified by any conspicuous findings in electrocardiography (ECG), exercise testing, or echocardiography. For further diagnostics, coronary angiography via computed tomography is the first-line approach if the probability lies between 5% and 50%. For probabilities of 50-85% procedures for imaging-based ischemia detection are indicated, while for even higher probabilities immediate invasive diagnostics are given priority. The treatment includes intensive risk modification, medicinal anti-anginal treatment and finally revascularization by coronary intervention or bypass surgery. In the absence of high-risk constellations a medication-based approach should be initially preferred, with revascularization indicated if symptoms persist. The new guidelines also extensively address angina and ischemia without obstructive coronary lesions. In this context, intensive risk modification and initial medication treatment are again recommended.

Long-term outcomes after stress echocardiography in real-world practice: a 5-year follow-up of the UK EVAREST study

AIMS

Stress echocardiography is widely used to assess patients with chest pain. The clinical value of a positive or negative test result to inform on likely longer-term outcomes when applied in real-world practice across a healthcare system has not been previously reported.

METHODS AND RESULTS

Five thousand five hundred and three patients recruited across 32 UK NHS hospitals between 2018 and 2022, participating in the EVAREST/BSE-NSTEP prospective cohort study, with data on medical outcomes up to 2023 available from NHS England were included in the analysis. Stress echocardiography results were related to outcomes, including death, procedures, hospital admissions, and relevant cardiovascular diagnoses, based on Kaplan-Meier analysis and Cox proportional hazard ratios (HRs). Median follow-up was 829 days (interquartile range 224-1434). A positive stress echocardiogram was associated with a greater risk of myocardial infarction [HR 2.71, 95% confidence interval (CI) 1.73-4.24, P < 0.001] and a composite endpoint of cardiac-related mortality and myocardial infarction (HR 2.03, 95% CI 1.41-2.93, P < 0.001). Hazard ratios increased with ischaemic burden. A negative stress echocardiogram identified an event-free 'warranty period' of at least 5 years in patients with no prior history of coronary artery disease and 4 years for those with disease.

CONCLUSION

In real-world practice, the degree of myocardial ischaemia recorded by clinicians at stress echocardiography correctly categorizes risk of future events over the next 5 years. Reporting a stress echocardiogram as negative correctly identifies patients with no greater than a background risk of cardiovascular events over a similar time period.

Quantitative Plaque Characteristics/Pericoronary Fat Attenuation Index and Acute Coronary Syndrome in Patients With Stable Angina Pectoris

OBJECTIVE

Vascular inflammation affects acute coronary syndrome (ACS) occurrence in patients with stable angina. Coronary inflammation can be represented by the pericoronary fat attenuation index (FAI).This study investigated the quantitative prognostic value of plaque characteristics and FAI in patients with stable angina.

METHODS

Risk factors for ACS occurrence in patients with stable angina pectoris were retrospectively analyzed. The diagnostic value of FAI and plaque characteristics for ACS occurrence in these patients were determined; Kaplan-Meier curves were used to predict ACS event incidence.

RESULTS

After postpropensity score matching, data of 60 and 130 patients with and without ACS, respectively, were analyzed. Pericoronary FAI, lipid volume, and lipid percentage in the narrowest segment significantly improved ACS diagnosis in patients with stable angina. Luminal stenosis ≥50% and FAI >-88 Hounsfield units (HU) were independent risk factors for ACS occurrence in patients with stable angina. Perileft anterior descending artery (LAD) FAI >-88 HU better predicted ACS occurrence in patients with stable angina than did peri-LAD FAI ≤-88 HU.

CONCLUSIONS

In patients with stable angina, lipid volume and percentage and pericoronary FAI improved the diagnostic ability of luminal stenosis for ACS occurrence. Furthermore, peri-LAD FAI >-88 HU could predict ACS occurrence.

Coronary CT angiography-guided management of patients with stable chest pain: 10-year outcomes from the SCOT-HEART randomised controlled trial in Scotland

BACKGROUND

The Scottish Computed Tomography of the Heart (SCOT-HEART) trial demonstrated that management guided by coronary CT angiography (CCTA) improved the diagnosis, management, and outcome of patients with stable chest pain. We aimed to assess whether CCTA-guided care results in sustained long-term improvements in management and outcomes.

METHODS

SCOT-HEART was an open-label, multicentre, parallel group trial for which patients were recruited from 12 outpatient cardiology chest pain clinics across Scotland. Eligible patients were aged 18-75 years with symptoms of suspected stable angina due to coronary heart disease. Patients were randomly assigned (1:1) to standard of care plus CCTA or standard of care alone. In this prespecified 10-year analysis, prescribing data, coronary procedural interventions, and clinical outcomes were obtained through record linkage from national registries. The primary outcome was coronary heart disease death or non-fatal myocardial infarction on an intention-to-treat basis. This trial is registered at ClinicalTrials.gov (NCT01149590) and is complete.

FINDINGS

Between Nov 18, 2010, and Sept 24, 2014, 4146 patients were recruited (mean age 57 years [SD 10], 2325 [56·1%] male, 1821 [43·9%] female), with 2073 randomly assigned to standard care and CCTA and 2073 to standard care alone. After a median of 10·0 years (IQR 9·3-11·0), coronary heart disease death or non-fatal myocardial infarction was less frequent in the CCTA group compared with the standard care group (137 [6·6%] vs 171 [8·2%]; hazard ratio [HR] 0·79 [95% CI 0·63-0·99], p=0·044). Rates of all-cause, cardiovascular, and coronary heart disease death, and non-fatal stroke, were similar between the groups (p>0·05 for all), but non-fatal myocardial infarctions (90 [4·3%] vs 124 [6·0%]; HR 0·72 [0·55-0·94], p=0·017) and major adverse cardiovascular events (172 [8·3%] vs 214 [10·3%]; HR 0·80 [0·65-0·97], p=0·026) were less frequent in the CCTA group. Rates of coronary revascularisation procedures were similar (315 [15·2%] vs 318 [15·3%]; HR 1·00 [0·86-1·17], p=0·99) but preventive therapy prescribing remained more frequent in the CCTA group (831 [55·9%] of 1486 vs 728 [49·0%] of 1485 patients with available data; odds ratio 1·17 [95% CI 1·01-1·36], p=0·034).

INTERPRETATION

After 10 years, CCTA-guided management of patients with stable chest pain was associated with a sustained reduction in coronary heart disease death or non-fatal myocardial infarction. Identification of coronary atherosclerosis by CCTA improves long-term cardiovascular disease prevention in patients with stable chest pain.

FUNDING

The Chief Scientist Office of the Scottish Government Health and Social Care Directorates, Edinburgh and Lothian's Health Foundation Trust, British Heart Foundation, and Heart Diseases Research Fund.

Association between symptom characteristics and disease severity in patients suspected of coronary artery disease

BACKGROUND

Discrepancies often exist between patient-reported symptoms and diagnostic test findings in patients with suspected obstructive coronary artery disease (CAD).

OBJECTIVES

To quantify the association between patient-reported symptoms and the diagnosis of severe stenosis in patients with suspected obstructive CAD.

METHODS

Two large-scale cohorts of patients with new-onset symptoms suggestive of obstructive CAD were evaluated. Chest discomfort was assessed by typicality, location, type, exertional/stress factors, and relief with rest/nitroglycerine. Patients underwent non-invasive diagnostic testing (coronary computed tomographic angiography (CCTA) or functional testing), followed by test-result-driven invasive coronary angiography (ICA). Severe stenosis was defined as ≥70 ​% diameter stenosis on ICA. Sensitivity analyses included CCTA stenosis, functional abnormalities, and revascularization.

RESULTS

Of 14,410 patients, 2093 (14.5 ​%) were referred for ICA, and 765 (5.3 ​%) were diagnosed with severe stenosis. Patients with typical angina (n ​= ​224) had higher odds of being diagnosed with severe stenosis on ICA (OR and 95 ​% CIs: 2.84 [2.40-3.34]) than those with atypical or non-anginal symptoms. In patients diagnosed with severe stenosis on ICA, those with exertional/stress factors (n ​= ​418; OR [95 ​% CI]: 2.50 [2.16-2.90]) and relief with rest/nitroglycerine (n ​= ​318, 2.28; [1.96-2.65]) had higher odds compared to those without. Patients reporting pressure or burning pain had higher odds of severe stenosis. Associations were consistent across sex and age groups, and sensitivity references.

CONCLUSIONS

Exertional/stress-related chest discomfort and relief with rest/nitroglycerine increased the odds of severe stenosis in patients with suspected CAD undergoing test-result-driven ICA, while location and type of chest pain were less associated, with no differences across sex or age groups.

Computed tomography coronary angiography as an alternative to invasive coronary angiography in preoperative evaluation for mitral surgery

OBJECTIVE

To assess the effectiveness of noninvasive coronary computed tomography angiography (CTA) as an alternative to traditional invasive coronary angiography (ICA) for preoperative evaluation of low-risk patients with an indication for nonemergent mitral surgery and to assess any difference in adverse outcomes from this strategy.

METHODS

This was a retrospective cohort study from a single center with data collected from July 2014 to June 2020 for 1576 patients undergoing mitral valve surgery of all etiologies, excluding patients requiring coronary artery bypass surgery. We performed a 1:2 propensity score matching for patients evaluated with CTA (n = 345) to those evaluated with ICA (n = 602). The primary outcome was a composite of major adverse events in the immediate postoperative period, including death, stroke, new-onset renal failure, postoperative cardiac arrest, need for unplanned coronary artery bypass grafting or percutaneous coronary re-vascularization. The odds ratio was calculated for occurrence of major adverse events in the CTA group compared with the catheterization group.

RESULTS

The mean age (standard deviation) was 55.62 years (11.54) for the CTA group and 58.22 years (10.11) for the ICA group. In the CTA group 334 (96.8%) and from the ICA group 582 (96.7%) patients underwent mitral valve repair. Thirteen (3.8%) patients in the CTA group experienced a major adverse event compared with 25 (4.2%) patients in the ICA group. Of these, there were no mortalities in the CTA group but 1 (0.2%) operative mortality in the ICA group. Four (1.2%) patients in the CTA group had a postoperative stroke compared with 3 (0.5%) patients in the ICA group. One (0.3%) patient in the CTA group required renal-replacement therapy postoperatively compared with 11 (1.8%) in the ICA group. Percutaneous coronary intervention was required in 1 (0.3%) patient in CTA group and 2 (0.3%) patients in ICA group for a coronary complication of valve surgery despite nonobstructive coronary anatomy being confirmed in both groups preoperatively. The odds ratio for having a major adverse event when worked up by CTA compared with ICA was 0.904 (0.443, 1.761).

CONCLUSIONS

There were no increased odds of experiencing a major adverse event for low-risk patients undergoing elective mitral valve surgery and preoperative coronary evaluation with CTA compared with ICA. These data have modified our practice pattern, where we now offer coronary CTA to all elective patients who are low risk for coronary artery disease.

Prognostic Implication of Computational Angiography-Derived Fractional Flow Reserve in Patients With Nonobstructive Coronary Artery Disease

BACKGROUND

Risk stratification of patients with symptomatic nonobstructive coronary artery disease remains uncertain. Our study assessed the clinical value of single-vessel, multivessel, and 3-vessel computational angiography-derived fractional flow reserve (caFFR) measurement in patients with nonobstructive coronary artery disease.

METHODS AND RESULTS

We enrolled patients with ≤50% stenosis with a caFFR value ≥0.8 in all 3 coronary arteries on coronary angiography. The sum of caFFR values in the 3 vessels was computed for each patient. Patient stratification was based on the median value of the following criteria: single-vessel analysis, multivessel analysis, and 3-vessel analysis. The primary end point of this study was major adverse cardiac events at 5 years, defined as a composite of cardiac death, myocardial infarction, and ischemia-driven revascularization. A total of 490 patients were included. The 5-year major adverse cardiac event rates in single-vessel analysis were statistically insignificant between low- and high-caFFR groups (left anterior descending artery [P=0.163]; left circumflex artery [P=0.797]; right coronary artery [P=0.127]). In multivessel analysis, patients in the multiple-vessel low-caFFR group (with 2-3 vessels lower than median value of all coronary arteries) showed an increased risk of 5-year major adverse cardiac events compared with patients in the single-vessel low-caFFR group (0-1 vessel) (hazard ratio [HR], 2.648 [95% CI, 1.141-6.145]; P=0.023). In 3-vessel analysis, patients in the low 3-vessel caFFR group demonstrated a greater 5-year major adverse cardiac event risk than the high 3-vessel caFFR group (HR, 2.43 [95% CI, 1.087-5.433]; P=0.031).

CONCLUSIONS

We demonstrated that both multiple-vessel and 3-vessel caFFR measurements serve as valuable prognostic indicators for risk assessment in patients with nonobstructive coronary artery disease.

Acoustic-based rule-out of stable coronary artery disease: the FILTER-SCAD trial

BACKGROUND AND AIMS

Overtesting of low-risk patients with suspect chronic coronary syndrome (CCS) is widespread. The acoustic-based coronary artery disease (CAD)-score has superior rule-out capabilities when added to pre-test probability (PTP). FILTER-SCAD tested whether providing a CAD-score and PTP to cardiologists was superior to PTP alone in limiting testing.

METHODS

At six Danish and Swedish outpatient clinics, patients with suspected new-onset CCS were randomized to either standard diagnostic examination (SDE) with PTP, or SDE plus CAD-score, and cardiologists provided with corresponding recommended diagnostic flowcharts. The primary endpoint was cumulative number of diagnostic tests at one year and key safety endpoint major adverse cardiac events (MACE).

RESULTS

In total, 2008 patients (46% male, median age 63 years) were randomized from October 2019 to September 2022. When randomized to CAD-score (n = 1002), it was successfully measured in 94.5%. Overall, 13.5% had PTP ≤ 5%, and 39.5% had CAD-score ≤ 20. Testing was deferred in 22% with no differences in diagnostic tests between groups (P for superiority = .56). In the PTP ≤ 5% subgroup, the proportion with deferred testing increased from 28% to 52% (P < .001). Overall MACE was 2.4 per 100 person-years. Non-inferiority regarding safety was established, absolute risk difference 0.49% (95% confidence interval -1.96-0.97) (P for non-inferiority = .003). No differences were seen in angina-related health status or quality of life.

CONCLUSIONS

The implementation strategy of providing cardiologists with a CAD-score alongside SDE did not reduce testing overall but indicated a possible role in patients with low CCS likelihood. Further strategies are warranted to address resistance to modifying diagnostic pathways in this patient population.

Uncertainty Quantification and Sensitivity Analysis for Non-invasive Model-Based Instantaneous Wave-Free Ratio Prediction

The main objectives of this work are to validate a 1D-0D unsteady solver with a distributed stenosis model for the patient-specific estimation of resting haemodynamic indices and to assess the sensitivity of instantaneous wave-free ratio (iFR) predictions to uncertainties in input parameters. We considered 52 patients with stable coronary artery disease, for which 81 invasive iFR measurements were available. We validated the performance of our solver compared to 3D steady-state and transient results and invasive measurements. Next, we used a polynomial chaos approach to characterise the uncertainty in iFR predictions based on the inputs associated with boundary conditions (coronary flow, compliance and aortic/left ventricular pressures) and vascular geometry (radius). Agreement between iFR and the ratio between cardiac cycle averaged distal and aortic pressure waveforms (restingP d / P a $$ {P}_d/{P}_a $$ ) obtained through 1D-0D and 3D models was satisfactory, with a bias of 0.0-0.005 (±0.016-0.026). The sensitivity analysis showed that iFR estimation is mostly affected by uncertainties in vascular geometry and coronary flow (steady-state parameters). In particular, our 1D-0D method overestimates invasive iFR measurements, with a bias of -0.036 (±0.101), indicating that better flow estimates could significantly improve our modelling pipeline. Conversely, we showed that standard pressure waveforms could be used for simulations, since the impact of uncertainties related to inlet-pressure waveforms on iFR prediction is negligible. Furthermore, while compliance is the most relevant transient parameter, its effect on iFR estimates is negligible compared to that of vascular geometry and flow. Finally, we observed a strong correlation between iFR and restingP d / P a $$ {P}_d/{P}_a $$ , suggesting that steady-state simulations could replace unsteady simulations for iFR prediction.

Accuracy of dynamic stress CT myocardial perfusion in patients with suspected non-ST elevation myocardial infarction

Coronary CT angiography (CCTA) and dynamic stress CT myocardial perfusion (CT-MPI) are established modalities in the analysis of patients with chronic coronary syndromes. Their role in patients with suspected non-ST elevation myocardial infarction (NSTEMI) is unknown. CCTA with CT-MPI might assist in the triage of NSTEMI patients to the Cath lab. We investigated the correlation of significant epicardial lesions by CT-MPI in addition to CCTA compared to invasive coronary angiography (ICA) with fractional flow reserve (FFR) in patients with NSTEMI. Twenty NSTEMI patients scheduled for ICA were enrolled in this study with planned ICA. CCTA and CT-MPI was performed pre-ICA. For each coronary artery, the presence or absence of significant lesions was interpreted by CCTA with CT-MPI, using an FFR of ≤ 0.8 or angiographic culprit (stenosis > 90%, suspected plaque rupture) as reference. The main outcome was the per-vessel correlation. Sixteen out of 20 patients had a culprit lesion that required immediate revascularization. CCTA with ≥ 50% stenosis demonstrated a per vessel sensitivity and specificity for the detection of significant stenosis of respectively 100% (95% CI: 86-100%) and 75% (95% CI: 58-88%). CCTA with CT-MPI showed a lower sensitivity 90% (95% CI: 70-99%) but higher specificity of 100% (95% CI: 90-100%). CCTA with CT-MPI exhibits a strong correlation for identifying significant CAD in patients with NSTEMI. Thereby, it might assist in the triage of ICA in NSTEMI patients.

Cost-effectiveness of ultrahigh-resolution photon-counting detector coronary CT angiography for the evaluation of stable chest pain

BACKGROUND

The increased specificity of ultrahigh-resolution (UHR) photon-counting detector (PCD)-CT over energy-integrating detector (EID)-CT for coronary CT angiography (CCTA) could defer unwarranted downstream tests. The objective of the study was to simulate the cost-effectiveness of UHR CCTA in stable chest pain patients with coronary calcifications.

METHODS

A decision and simulation model was developed using Monte Carlo simulations with 1000 bootstrap resamples to estimate the costs associated with PCD-CT in lieu of EID-CT for CCTA and the referral for subsequent testing. The model was constructed using the diagnostic accuracy metrics of 55 coronary lesions in patients who underwent CCTA on both CT systems and subsequent invasive coronary angiography (ICA). Sensitivity and specificity were defined for each Coronary Artery Disease Reporting and Data System category. The aggregate healthcare expenditures were derived from the hospital billing system.

RESULTS

Assuming a projected cohort of 15,000 patients over the lifetime of the PCD-CT, its implementation resulted in a 18.9 ​% reduction in the number of functional follow-up tests (6330.3 ​± ​59.5 vs. 5135.7 ​± ​60.6, p ​< ​0.001), a 6.0 ​% reduction in performed ICAs (1447.7 ​± ​36.2 vs. 1360.2 ​± ​34.7, p ​< ​0.001), and a 9.4 ​% decrease in major procedure-related complications. Over a 10-year expected life expectancy, PCD-CT led to an average cost saving of $794.50 ​± ​18.50 per patient and an overall cost difference of $11,917,500 ​± ​4,350,169.

CONCLUSIONS

PCD-CT has the potential to reduce the financial burden on healthcare systems and procedure-related complications for stable chest pain patients with coronary calcification when compared to EID-CT.

Cardiac biomarkers and CT coronary angiography for the assessment of coronary heart disease

Over the last 30 years, the widespread use of cardiac biomarkers has transformed the diagnostic evaluation of patients with coronary heart disease. Cardiac troponin is integral to the definition of acute myocardial infarction. High-sensitivity cardiac troponin (hs-cTn) assays can improve risk stratification to facilitate both the rapid rule out of myocardial infarction and prediction of future cardiovascular events. Numerous circulating biomarkers representing different pathological pathways improve prediction of atherosclerotic cardiovascular disease (ACVD) and coronary artery disease (CAD). In parallel, coronary computed tomography angiography (CCTA) has become the most widely used imaging modality for the evaluation of patients with possible angina. CCTA now allows for the quantification of coronary calcification, atherosclerotic plaque volume and different plaque characteristics, enabling the identification high-risk features and inflammation. In the future, the use of CCTA is likely to extend to risk stratification for the prevention of ACVD. As such, how to integrate these diagnostic and prognostic circulating and imaging biomarkers is a topic of considerable interest. This review aims to describe current status and future possibilities for the integration of CCTA and cardiac biomarker testing to improve the identification and treatment of individuals with coronary heart disease and heightened cardiovascular risk.

Noninvasive machine-learning models for the detection of lesion-specific ischemia in patients with stable angina with intermediate stenosis severity on coronary CT angiography

This study proposed noninvasive machine-learning models for the detection of lesion-specific ischemia (LSI) in patients with stable angina with intermediate stenosis severity based on coronary computed tomography (CT) angiography. This single-center retrospective study analyzed 76 patients (99 vessels) with stable angina who underwent coronary CT angiography (CCTA) and had intermediate stenosis severity (40-69%) on invasive coronary angiography. LSI, defined as a resting full-cycle ratio < 0.86 or fractional flow reserve ≤ 0.80, was determined in 40 patients (46 vessels) using a hybrid resting full-cycle ratio-fractional flow reserve strategy. The resting full-cycle ratio and/or fractional flow reserve were measured using invasive coronary angiography as references for functional severity indices of coronary stenosis in the machine-learning models. LSI detection models were constructed using noninvasive machine-learning models that predicted the resting full-cycle ratio and fractional flow reserve by feeding machine-learning models with image features extracted from CCTA. The diagnostic performance of the proposed LSI detection models was assessed using a nested 10-fold cross-validation test. The LSI detection models with the highest diagnostic performance achieved an accuracy of 0.88 (95% CI: 0.81, 0.94), sensitivity of 0.78 (95% CI: 0.70, 0.86) and specificity of 0.96 (95% CI: 0.92, 1.00) on a vessel basis and 0.88 (95% CI: 0.81, 0.95), 0.80 (95% CI: 0.70, 0.86) and 0.97 (95% CI: 0.92, 1.00), respectively, on a patient basis. These findings suggest that LSI detection models with features extracted from CCTA can noninvasively detect LSI in patients with stable angina with intermediate stenosis severity.

Right coronary artery pericoronary fat attenuation index as a future predictor for acute coronary events in nonobstructive coronary artery disease - a prospective single centre study

AIM

Evaluation of pericoronary adipose tissue changes induced by inflammation by non-invasive techniques is challenging.

PURPOSE

To find the association between pericoronary adipose tissue attenuation (FAI) changes and future acute coronary events in nonobstructive coronary artery disease.

MATERIALS AND METHODS

Ours was a single-centre, prospective observational study on patients with atypical chest pain who underwent coronary computed tomography angiography (CCTA). In patients with CADRADS 1 to 3 nonobstructive coronary artery disease (CAD), pericoronary FAI was measured around the proximal right coronary artery (RCA) and coronary artery segment with plaque using semi-automated postprocessing software. Patients were followed up for development of acute coronary events (ACE). Kaplan-Meier curves were used to see event-free survival rates.

RESULTS

Of 120 patients with a mean follow-up period of 67 months, 21 patients developed acute coronary events. RCA-FAI and lesion FAI of patients with ACE were significantly higher as compared to patients without events. ROC curve analysis showed RCA-FAI as the best predictor of ACE at a cut-off point of > -77.3 Hounsfield unit (HU) (with an AUC of 0.915) with high sensitivity (95.24%), specificity (83.84%), and negative predictive value (98.80%). On multivariate analysis, RCA-FAI, diabetes mellitus, and stenosis ≥50% were independent risk factors of ACE with hazard ratios of 1.335 (1.173-1.518), 4.950 (1.716-14.278), and 7.446 (2.257-24.566), respectively.

CONCLUSION

RCA FAI can predict ACE in nonobstructive coronary artery disease patients. Detection of high RCA FAI of > -77.3 HU on CCTA can help to identify high-risk patients who need regular follow-up and early initiation of interventions.

Comprehensive Analysis of Cardiovascular Diseases: Symptoms, Diagnosis, and AI Innovations

Cardiovascular diseases are some of the underlying reasons contributing to the relentless rise in mortality rates across the globe. In this regard, there is a genuine need to integrate advanced technologies into the medical realm to detect such diseases accurately. Moreover, numerous academic studies have been published using AI-based methodologies because of their enhanced accuracy in detecting heart conditions. This research extensively delineates the different heart conditions, e.g., coronary artery disease, arrhythmia, atherosclerosis, mitral valve prolapse/mitral regurgitation, and myocardial infarction, and their underlying reasons and symptoms and subsequently introduces AI-based detection methodologies for precisely classifying such diseases. The review shows that the incorporation of artificial intelligence in detecting heart diseases exhibits enhanced accuracies along with a plethora of other benefits, like improved diagnostic accuracy, early detection and prevention, reduction in diagnostic errors, faster diagnosis, personalized treatment schedules, optimized monitoring and predictive analysis, improved efficiency, and scalability. Furthermore, the review also indicates the conspicuous disparities between the results generated by previous algorithms and the latest ones, paving the way for medical researchers to ascertain the accuracy of these results through comparative analysis with the practical conditions of patients. In conclusion, AI in heart disease detection holds paramount significance and transformative potential to greatly enhance patient outcomes, mitigate healthcare expenditure, and amplify the speed of diagnosis.

Cohort profile: AI-driven national Platform for CCTA for clinicaL and industriaL applicatiOns (APOLLO)

PURPOSE

Coronary CT angiography (CCTA) is well established for the diagnostic evaluation and prognostication of coronary artery disease (CAD). The growing burden of CAD in Asia and the emergence of novel CT-based risk markers highlight the need for an automated platform that integrates patient data with CCTA findings to provide tailored, accurate cardiovascular risk assessments. This study aims to develop an artificial intelligence (AI)-driven platform for CAD assessment using CCTA in Singapore's multiethnic population. We will conduct a hybrid retrospective-prospective recruitment of patients who have undergone CCTA as part of the diagnostic workup for CAD, along with prospective follow-up for clinical endpoints. CCTA images will be analysed locally and by a core lab for coronary stenosis grading, Agatston scoring, epicardial adipose tissue evaluation and plaque analysis. The images and analyses will also be uploaded to an AI platform for deidentification, integration and automated reporting, generating precision AI toolkits for each parameter.

PARTICIPANTS

CCTA images and baseline characteristics have been collected and verified for 4196 recruited patients, comprising 75% Chinese, 6% Malay, 10% Indian and 9% from other ethnic groups. Among the participants, 41% are female, with a mean age of 55±11 years. Additionally, 41% have hypertension, 51% have dyslipidaemia, 15% have diabetes and 22% have a history of smoking.

FINDINGS TO DATE

The cohort data have been used to develop four AI modules for training, testing and validation. During the development process, data preprocessing standardised the format, resolution and other relevant attributes of the images.

FUTURE PLANS

We will conduct prospective follow-up on the cohort to track clinical endpoints, including cardiovascular events, hospitalisations and mortality. Additionally, we will monitor the long-term impact of the AI-driven platform on patient outcomes and healthcare delivery.

TRIAL REGISTRATION NUMBER

NCT05509010.

Management of acute chest pain in the Emergency Department: benefits of coronary computed tomography angiography

Acute chest pain (ACP) is a frequent cause of Emergency Department (ED) admissions, with millions of cases reported globally each year. Timely and accurate diagnosis is crucial due to the wide range of underlying causes, such as acute coronary syndrome (ACS), pulmonary embolism (PE), aortic dissection, and others. Misdiagnosis can lead to missed life-saving interventions or, alternatively, unnecessary hospitalizations, escalating healthcare costs. While risk stratification tools like the HEART, GRACE, and TIMI scores are useful, additional imaging is often required to achieve diagnostic precision. Coronary computed tomography angiography (CCTA) has shown significant potential in enhancing diagnostic accuracy and improving patient outcomes. In this review, we explore the challenges physicians encounter when evaluating ACP in the ED, emphasizing the utility of CCTA as a key diagnostic tool. Additionally, we present a clinical case that illustrates how CT scan effectively aids in diagnosing patients with ambiguous symptoms, with CT imaging playing a pivotal role in identifying the underlying pathology.

Sex-related differences in demographics, diagnosis and management of patients with chronic coronary syndromes

AIMS

The impact of sex-related factors on current clinical management and outcomes of chronic coronary syndromes (CCS) are unclear.

METHODS

All patients belonging to the prospective, nationwide START registry were included. Their baseline characteristics, diagnostic workup, revascularization strategy, pharmacological treatment and 1-year clinical outcomes were compared with respect to sex overall and in age tertiles.

RESULTS

A total of 5070 consecutive patients were included. Most patients were males (80.1%). As expected, the prevalence of females increased with age. Distribution of risk factors and history of cardiovascular disease were different depending on sex, as well as diagnostic workup, with lower use of exercise stress testing in women (25.1% vs. 36.7%, P < 0.0001). The use of coronary angiography was similar in the two groups. Women had lower rates of multivessel coronary artery disease (CAD) (33.0% vs. 40.6% P < 0.0001) and higher rates of nonobstructive CAD (18.3% vs. 11.3%, P < 0.0001). Rates of myocardial revascularization were similar, but women were more likely to receive percutaneous coronary intervention than men (84.3% vs. 77.8%, P < 0.0001) and less likely to receive surgical/hybrid revascularization (10.0% vs. 15.1%, P < 0.0001). At 12-month follow-up, no differences were observed for the combined endpoint of all-cause mortality, re-hospitalization for myocardial infarction, heart failure, stroke or myocardial revascularization between males and females; however, a significantly worse perceived quality of life was observed in women.

CONCLUSIONS

In a large nationwide cohort of patients with CCS, clinical outcomes were not different depending on sex. However, several differences in the diagnostic work-up, treatment strategies and quality of life were found between sexes.

Relationship Between Severity of Ischemia and Coronary Artery Disease for Different Stress Test Modalities in the ISCHEMIA Trial

BACKGROUND

The relationship between the extent and severity of stress-induced ischemia and the extent and severity of anatomic coronary artery disease (CAD) in patients with obstructive CAD is multifactorial and includes the intensity of stress achieved, type of testing used, presence and extent of prior infarction, collateral blood flow, plaque characteristics, microvascular disease, coronary vasomotor tone, and genetic factors. Among chronic coronary disease participants with site-determined moderate or severe ischemia, we investigated associations between ischemia severity on stress testing and the extent of CAD on coronary computed tomography angiography.

METHODS

Clinically indicated stress testing included nuclear imaging, echocardiography, cardiac magnetic resonance imaging, or nonimaging exercise tolerance test. Among those with preserved renal function who underwent coronary computed tomography angiography, we examined relationships between ischemia and CAD by coronary computed tomography angiography, overall, and by stress test modality, regardless of subsequent randomization. Core laboratories categorized ischemia as severe, moderate, mild, or none, while the extent and severity of anatomic CAD were categorized based on the modified Duke prognostic index.

RESULTS

Among 3601 participants with interpretable stress tests and coronary computed tomography angiography, ischemia severity was weakly associated with CAD extent/severity (r=0.27), with modest variability in strength of association by modality: nuclear (n=1532; r=0.40), echocardiography (n=827; r=0.15), cardiac magnetic resonance imaging (n=108; r=0.31), and exercise tolerance test (n=1134; r=0.18). The extent of infarction on nuclear imaging and echocardiography was weakly associated with CAD extent/severity.

CONCLUSIONS

Overall, ischemia severity on stress testing showed weak to moderate associations with the anatomic extent of CAD in this cohort with moderate or severe ischemia on local interpretation and controlled symptoms.

REGISTRATION

URL: https://www.clinicaltrials.gov; Unique identifier: NCT01471522.

The Role of Coronary Computed Tomography Angiography in the Diagnosis, Risk Stratification, and Management of Patients with Diabetes and Chest Pain

Coronary artery disease (CAD) affects over 200 million individuals globally, accounting for approximately 9 million deaths annually. Patients living with diabetes mellitus exhibit an up to fourfold increased risk of developing CAD compared to individuals without diabetes. Furthermore, CAD is responsible for 40 to 80 percent of the observed mortality rates among patients with type 2 diabetes. Patients with diabetes typically present with non-specific clinical complaints in the setting of myocardial ischemia, and as such, it is critical to select appropriate diagnostic tests to identify those at risk for major adverse cardiac events (MACEs) and for determining optimal management strategies. Studies indicate that patients with diabetes often exhibit more advanced atherosclerosis, a higher calcified plaque burden, and smaller epicardial vessels. The diagnostic performance of coronary computed tomographic angiography (CCTA) in identifying significant stenosis is well-established, and as such, CCTA has been incorporated into current clinical guidelines. However, the predictive accuracy of obstructive CAD in patients with diabetes has been less extensively characterized. CCTA provides detailed insights into coronary anatomy, plaque burden, epicardial vessel stenosis, high-risk plaque features, and other features associated with a higher incidence of MACEs. Recent evidence supports the efficacy of CCTA in diagnosing CAD and improving patient outcomes, leading to its recommendation as a primary diagnostic tool for stable angina and risk stratification. However, its specific benefits in patients with diabetes require further elucidation. This review examines several key aspects of the utility of CCTA in patients with diabetes: (i) the diagnostic accuracy of CCTA in detecting obstructive CAD, (ii) the effect of CCTA as a first-line test for individualized risk stratification for cardiovascular outcomes, (iii) its role in guiding therapeutic management, and (iv) future perspectives in risk stratification and the role of artificial intelligence.

Incremental prognostic value of 18F-fluorodeoxyglucose myocardial ischemic memory imaging for major adverse cardiovascular events in patients with suspected unstable angina

BACKGROUND

The additional prognostic value of 18F-flurodeoxyglucose positron emission tomography (18F-FDG PET) myocardial ischemic memory imaging for patients with suspected unstable angina (UA) is not well established. This study aimed to determine whether 18F-FDG PET imaging provides incremental prognostic information for predicting major adverse cardiac events (MACEs) compared to clinical risk factors, Global Registry of Acute Coronary Events (GRACE) score, and coronary artery calcium score (CACS) in patients with suspected UA.

METHODS

In this post hoc analysis of a prospective study, 265 patients suspected with UA (62.3% male, mean age: 65.0±9.4 years) were enrolled. 18F-FDG positivity was defined as focal or focal on diffuse uptake patterns. MACEs included cardiovascular death, acute myocardial infarction, heart failure, rehospitalization for UA, and stroke. Multivariable Cox regression was used to identify predictors of MACEs, and the incremental prognostic value of 18F-FDG PET imaging was assessed using the Concordance Index (C-index), net reclassification improvement (NRI), and integrated discrimination improvement (IDI).

RESULTS

Over a median follow-up of 25 months, 51 patients (19.2%) experienced MACEs. 18F-FDG positivity (hazard ratio [HR]=3.220, 95% confidence interval [CI]: 1.630-6.360, P<.001), as well as 18F-FDG standardized uptake ratio (HR=1.330, 95% CI: 1.131-1.564, P=.0006) and Extent (HR=1.045, 95% CI: 1.028-1.062, P<.0001), were independent predictors of MACE. The addition of 18F-FDG PET imaging significantly improved risk stratification beyond clinical factors, the GRACE score, and CACS, with improved C-index (.769 vs .688, P=.045), NRI (.324, P=.020), and IDI (.055, P=.027).

CONCLUSION

18F-FDG PET myocardial ischemic memory imaging significantly improves prognostic assessment for patients with suspected UA, providing valuable additional risk stratification beyond clinical risk factors, GRACE score, and CACS.

Pericoronary Fat Attenuation: Diagnosis and Clinical Implications

PURPOSE OF THE REVIEW

The purpose of this review is to evaluate the current state of knowledge regarding the technical challenges associated with the Post-Acquisition Fat Attenuation Index (PFAI). By examining the limitations and gaps in the current methodologies, this review aims to provide a comprehensive understanding of how various factors impact the accuracy and reliability of PFAI measurements.

RECENT FINDINGS

PFAI correlates with plaque instability, as inflammation in coronary plaque alters surrounding adipose tissue composition, increasing its water content and reducing lipid content, which is detectable via cardiac CT as increased attenuation. Recent studies have demonstrated PFA's prognostic value, with elevated levels linked to higher risks of cardiac events and plaque instability. A 2022 meta-analysis confirmed its association with major adverse cardiac events. Machine learning algorithms incorporating PFA and additional imaging features have further enhanced risk prediction beyond traditional metrics. Pericoronary fat attenuation is a promising marker for assessing coronary inflammation and could be useful in predicting plaque development, rupture, and monitoring treatment response, though further prospective studies and technical standardization are needed to fully establish its clinical benefits.

Association Between Lipoprotein(a) and Obstructive Coronary Artery Disease and High-Risk Plaque: Insights From the PROMISE Trial

The role of lipoprotein (a) (Lp[a]) in the development of obstructive coronary artery disease (CAD) and high-risk plaque (HRP) in primary prevention patients with stable chest pain is unknown. We sought to evaluate the relation of Lp(a), independent of low-density lipoprotein cholesterol (LDL-C), with the presence of obstructive CAD and HRP to improve understanding of the residual risk imparted by Lp(a) on CAD. We performed a secondary analysis in Prospective Multicenter Imaging Study for Evaluation of Chest Pain (PROMISE) Trial participants who had coronary computed tomographic angiography (CTA) performed and Lp(a) data available. Lp(a) concentration was analyzed as a binary variable, with elevated Lp(a) defined as ≥50 mg/100 ml. "Stenosis ≥50%" was defined as ≥50% coronary artery stenosis in any epicardial vessel, and "stenosis ≥70%" was defined as ≥70% coronary artery stenosis in any epicardial vessel and/or ≥50% left main coronary artery stenosis. HRP was defined as presence of plaque on CTA imaging with evidence of positive remodeling, low computed tomography attenuation, or napkin-ring sign. Multivariate logistic regression models were constructed to evaluate the association between Lp(a) and the outcomes of obstructive CAD and HRP stratified by LDL-C ≥100 versus <100 mg/100 ml. Of the 1,815 patients who underwent CTA and had Lp(a) data available, those with elevated Lp(a) were more commonly women and Black than those with lower Lp(a). Elevated Lp(a) was associated with stenosis ≥50% (odds ratio 1.57, 95% confidence interval 1.14 to 2.15, p = 0.005) and stenosis ≥70% (odds ratio 2.05, 95% confidence interval 1.34 to 3.11, p = 0.0008) in the multivariate models, and this relation was not modified by LDL-C ≥100 versus <100 mg/100 ml (interaction p >0.4). Elevated Lp(a) was not associated with HRP when adjusted for obstructive CAD. This study of patients without known CAD found that elevated Lp(a) ≥50 mg/100 ml was independently associated with the presence of obstructive CAD regardless of controlled versus uncontrolled LDL-C but was not independently associated with HRP when stenosis ≥50% or ≥70% was accounted for. Further research is warranted to delineate the role of Lp(a) in the residual risk for atherosclerotic cardiovascular disease that patients may have despite optimal LDL-C lowering.

Myocardial Ischemic Syndromes: A New Nomenclature to Harmonize Evolving International Clinical Practice Guidelines

Since the 1960s, cardiologists have adopted several binary classification systems for acute myocardial infarction (MI) that facilitated improved patient management. Conversely, for chronic stable manifestations of myocardial ischemia, various classifications have emerged over time, often with conflicting terminology-eg, "stable coronary artery disease" (CAD), "stable ischemic heart disease," and "chronic coronary syndromes" (CCS). While the 2019 European guidelines introduced CCS to impart symmetry with "acute coronary syndromes" (ACS), the 2023 American guidelines endorsed the alternative term "chronic coronary disease." An unintended consequence of these competing classifications is perpetuation of the restrictive terms "coronary" and 'disease', often connoting only a singular obstructive CAD mechanism. It is now important to advance a more broadly inclusive terminology for both obstructive and non-obstructive causes of angina and myocardial ischemia that fosters conceptual clarity and unifies dyssynchronous nomenclatures across guidelines. We, therefore, propose a new binary classification of "acute myocardial ischemic syndromes" and "non-acute myocardial ischemic syndromes," which comprises both obstructive epicardial and non-obstructive pathogenetic mechanisms, including microvascular dysfunction, vasospastic disorders, and non-coronary causes. We herein retain accepted categories of ACS, ST-segment elevation MI, and non-ST-segment elevation MI, as important subsets for which revascularization is of proven clinical benefit, as well as new terms like ischemia and MI with non-obstructive coronary arteries. Overall, such a more encompassing nomenclature better aligns, unifies, and harmonizes different pathophysiologic causes of myocardial ischemia and should result in more refined diagnostic and therapeutic approaches targeted to the multiple pathobiological precipitants of angina pectoris, ischemia, and infarction.

2024 AHA/ACC/ACS/ASNC/HRS/SCA/SCCT/SCMR/SVM Guideline for Perioperative Cardiovascular Management for Noncardiac Surgery: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines

AIM

The "2024 AHA/ACC/ACS/ASNC/HRS/SCA/SCCT/SCMR/SVM Guideline for Perioperative Cardiovascular Management for Noncardiac Surgery" provides recommendations to guide clinicians in the perioperative cardiovascular evaluation and management of adult patients undergoing noncardiac surgery.

METHODS

A comprehensive literature search was conducted from August 2022 to March 2023 to identify clinical studies, reviews, and other evidence conducted on human subjects that were published in English from MEDLINE (through PubMed), EMBASE, the Cochrane Library, the Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline.

STRUCTURE

Recommendations from the "2014 ACC/AHA Guideline on Perioperative Cardiovascular Evaluation and Management of Patients Undergoing Noncardiac Surgery" have been updated with new evidence consolidated to guide clinicians; clinicians should be advised this guideline supersedes the previously published 2014 guideline. In addition, evidence-based management strategies, including pharmacological therapies, perioperative monitoring, and devices, for cardiovascular disease and associated medical conditions, have been developed.

2024 AHA/ACC/ACS/ASNC/HRS/SCA/SCCT/SCMR/SVM Guideline for Perioperative Cardiovascular Management for Noncardiac Surgery: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines

AIM

The "2024 AHA/ACC/ACS/ASNC/HRS/SCA/SCCT/SCMR/SVM Guideline for Perioperative Cardiovascular Management for Noncardiac Surgery" provides recommendations to guide clinicians in the perioperative cardiovascular evaluation and management of adult patients undergoing noncardiac surgery.

METHODS

A comprehensive literature search was conducted from August 2022 to March 2023 to identify clinical studies, reviews, and other evidence conducted on human subjects that were published in English from MEDLINE (through PubMed), EMBASE, the Cochrane Library, the Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline.

STRUCTURE

Recommendations from the "2014 ACC/AHA Guideline on Perioperative Cardiovascular Evaluation and Management of Patients Undergoing Noncardiac Surgery" have been updated with new evidence consolidated to guide clinicians; clinicians should be advised this guideline supersedes the previously published 2014 guideline. In addition, evidence-based management strategies, including pharmacological therapies, perioperative monitoring, and devices, for cardiovascular disease and associated medical conditions, have been developed.

Contact with general practice in patients with suspected chronic coronary syndrome before and after CT angiography compared with the general population

BACKGROUND

Most patients undergoing coronary computed tomography angiography (CCTA) to diagnose coronary artery disease (CAD) are referred from general practitioners (GPs). The burden of contacts to GP in relation to investigation of suspected CAD is unknown.

METHODS AND RESULTS

All patients undergoing CCTA in Western Denmark from 2014 to 2022 were included. CCTA stenosis was defined as diameter stenosis of ≥50%. Patients with and without stenosis were matched, in each group, 1:5 to a reference population based on birth year, gender, and municipality using data from national registries. All GP visits were registered up to 5 years preceding and 1 year after the CTA and stratified by gender and age. Charlson comorbidity index (CCI) was calculated in all groups.Of the 62 512 patients included, 12 886 had a stenosis, while 49 626 did not. Patients in both groups had a substantially higher GP visit frequency compared with reference populations. In the year of coronary CTA, the median GP contacts in patients with stenosis were 11 (6-17) vs. 6 (2-11) in the reference population (P < 0.001), and in patients without stenosis, the median GP contacts were 10 (6-17) vs. 5 (2-11) (P < 0.001). These findings were consistent across age and gender. CCI was higher among both patients with and without stenosis compared with reference groups.

CONCLUSION

In patients undergoing CCTA to diagnose CAD, a substantially increased frequency of contacts to GP was observed in the 5-year period prior to examination compared with the reference populations, regardless of the CCTA findings. Obtaining the CCTA result did not seem to substantially affect the GP visit frequency.

Tortuosity of the left anterior descending artery is associated with hypertension and is not independently related to physical performance: A cardiac computed tomography study

BACKGROUND

Coronary tortuosity (CorT) is frequently observed in invasive angiography, though its aetiology and clinical significance remain ambiguous. Prior research has indicated possible links between CorT and factors such as hypertension, age, and calcium scores in the left anterior descending (LAD) artery. The aim of this study was to examine and optimize the usage of coronary computed tomography angiography (CCTA) with vessel tracking to explore these associations.

METHODS

Observational sub-study of the single centre randomised controlled CATCH-trial. From the original study 600 participants, who underwent CCTA, 250 were randomly selected. Clinical data and patient risk factors were sourced from medical records and structured interviews. Tortuosity of the LAD was quantified by calculating the ratio of the actual vessel-length to the straight-line distance.

RESULTS

The final study population comprised 194 patients (56 patients were excluded due to poor image quality or inability to perform adequate vessel tracking). After adjusting for confounding variables, tortuosity was significantly associated with hypertension (p < 0.001), female gender (p = 0.01), and increasing age (p = 0.045). No significant correlation was observed between CorT and calcium scores. Univariate analysis indicated that higher CorT levels were linked to lower metabolic equivalents of task (METs) in bicycle tests (p = 0.003); however, this relationship became nonsignificant (p = 0.97) upon adjustment for age, gender, and hypertension.

CONCLUSIONS

Our findings suggest that increased CorT is most prevalent in patients with hypertension, advancing age, and female gender. Although higher tortuosity levels did not significantly impact METs during physical activity, further research is warranted to explore the underlying mechanisms of this relationship.

Detection of Coronary Artery Disease With Coronary Computed Tomography Angiography and Stress Testing in Candidates for Liver Transplant

Cardiac complications are the leading cause of morbidity and mortality in recipients of liver transplant (LT). Previous guidelines recommended stress testing to exclude coronary artery disease (CAD), although recent guidelines recommend coronary computed tomography angiography (CCTA). We aimed to assess the prevalence and predictors of CAD on CCTA and compare CCTA with stress testing in consecutive adult candidates for LT who underwent CAD noninvasive assessment between 2020 and 2023. Patients who underwent a stress test between January and December 2020 formed the stress cohort, and patients who underwent CCTA between January 2021 and September 2023 formed the CCTA cohort. There were 141 patients in the stress test cohort and 269 patients in the CCTA cohort. Stress test results were nondiagnostic or inconclusive in 18 patients (12.8%) whereas CCTA was nondiagnostic in 6 patients (2.2%). In patients evaluated with CCTA, mean coronary artery calcium (CAC) score was 332 ± 716 AU, with moderate or greater (>50%) stenosis in 33 patients (12.3%). New CAD was diagnosed in 158 patients (58.7%) using CCTA and in 5 patients (3.5%) using stress tests. Clinically actionable CAD (coronary artery calcium >100) on CCTA was present in 96 patients (35.7%). The number of CAD risk factors was associated with the presence of CAD on CCTA. In conclusion, there was a great burden of CAD, mainly nonobstructive, in a large cohort of candidates for LT who underwent CAD testing over a 4-year period. The current recommended risk-based evaluation of candidates for LT using CCTA as a first-line test was feasible and effective. Diagnosis of clinically actionable CAD on CCTA provides a vast opportunity for optimizing cardiac care in candidates for and recipients of LT.

Characteristics and Outcomes of Patients With a Moderate History, ECG, Age, Risk Factors, and Troponin (HEART) Score

Introduction Chest pain is a common, expensive cause of admission to the hospital from the Emergency Department (ED). The History, ECG, Age, Risk Factors, and Troponin (HEART) score is a risk stratification tool often used to determine the disposition of chest pain patients. This study evaluates the association of age, gender, HEART score, diabetes mellitus (DM), hypertension (HTN), hypercholesterolemia, family history (Fam Hx), and tobacco use with major adverse cardiovascular events (MACE) and hospital readmission. While low-risk HEART score patients are generally discharged and high-risk patients generally admitted, data is limited on the appropriate disposition strategy for moderate-risk patients. Our goal is to understand the risks of cardiovascular morbidity, the studies performed, and the factors associated with readmission in moderate HEART score patients. Methods A retrospective cohort study was conducted using ED records from March 1, 2018, to March 31, 2019. Patients with a moderate HEART score (4-6) were included. Data on additional testing and outcomes were collected. Statistical analyses included Pearson Chi-square tests and unadjusted and adjusted logistic regression to assess associations between explanatory variables and outcomes. Multicollinearity was assessed with all variance inflation factors below 1.3. To evaluate how well the logistic model performed an area under the curve (AUC) analysis was performed, with values of 0.68 (cardiovascular morbidity events) and 0.67 (readmission) respectively. No pre-existing AUC cutoff was used. Results The study included 959 patients with a moderate HEART score. The average age was 58.9 years, and 486 (50.7%) were male. Cardiovascular disease morbidity events occurred in 72 (7.5%) of patients, and 108 (11.3%) were readmitted within six weeks. Higher HEART scores, male gender, and diabetes were significantly associated with increased odds of cardiovascular morbidity. Male gender, tobacco use, and hypercholesterolemia were significantly associated with hospital readmission. The percutaneous intervention occurred in 60 (6.3%) patients, coronary bypass grafting in 10 (1.0%), and cerebrovascular accident in two (0.2%). Myocardial perfusion imaging was performed in 421 (43.9%) of patients and echocardiogram in 445 (46.4%), while computerized tomography coronary angiogram was performed in 99 (10.3%). No deaths were identified in our study. Discussion The findings suggest that higher HEART scores, male gender, and diabetes are significant predictors of cardiovascular morbidity, while male gender, tobacco use, and hypercholesterolemia predict hospital readmission. Reliance on ED records could limit study generalizability as we did not capture direct admissions. The retrospective design could introduce bias from confounding variables. Most of the testing and intervention during hospitalization could reasonably have been performed in an outpatient setting. Conclusion This study provides quantitative data on the utility of hospitalization for moderate-risk HEART score patients. The results support the potential for outpatient management in certain cases, especially those with HEART scores of 4. Future studies should include randomized controlled trials comparing the discharge of moderate HEART score patients with inpatient management.

Combined strategy of upfront CTCA and optimal treatment for stable chest pain: rationale and design of the CLEAR-CAD trial

BACKGROUND

Patients with stable chest pain suspected of coronary artery disease (CAD) usually undergo multiple diagnostic tests to confirm or rule out obstructive CAD. Some tests may not effectively assess the presence of CAD, precluding optimal treatment. A diagnostic strategy of upfront computed tomography coronary angiography (CTCA) combined with optimal medical therapy (OMT) tailored to the extent of CAD may be superior to standard care in preventing major adverse cardiac events.

STUDY DESIGN

The CLEAR-CAD trial is a prospective, open-label, multicentre, randomised, superiority trial of an upfront CTCA-guided strategy in 6444 patients presenting in an outpatient setting with suspected CAD compared with standard care, in approximately 30 participating centres in the Netherlands. The upfront CTCA-guided strategy consists of an initial CTCA which is assessed using the Coronary Artery Disease-Reporting and Data System (CAD-RADS 2.0). In patients without CAD (CAD-RADS 0) no specific cardiac medication is mandated. Patients with non-obstructive CAD (CAD-RADS 1-2) are treated with preventive OMT. Patients with obstructive CAD (CAD-RADS ≥ 3) are treated with preventive and anti-anginal OMT; in the presence of pharmacologically refractory symptoms patients undergo selective revascularisation after non-invasive functional imaging for myocardial ischaemia (≥ 10%). Patients with significant left main or proximal left anterior descending coronary artery stenosis on CTCA undergo direct invasive coronary angiography and subsequent revascularisation. The primary endpoint is the composite of all-cause death and myocardial infarction.

CONCLUSION

The CLEAR-CAD trial is the first randomised study to investigate the efficacy of a combined upfront CTCA-guided medical and selective revascularisation strategy in an outpatient setting with suspected CAD compared with standard care.

Cardiovascular Imaging in the Era of Precision Medicine: Insights from Advanced Technologies - A Narrative Review

Background and Aims

Cardiovascular diseases are responsible for a high mortality rate globally. Precision medicine has emerged as an essential tool for improving cardiovascular disease outcomes. In this context, using advanced imaging exams is fundamental in cardiovascular precision medicine, enabling more accurate diagnoses and customized treatments. This review aims to provide a concise review on how advanced cardiovascular imaging supports precision medicine, highlighting its benefits, challenges, and future directions.

Methods

A literature review was carried out using the Pubmed and Google Scholar databases, using search strategies that combined terms such as precision medicine, cardiovascular diseases, and imaging tests.

Results

More advanced analysis aimed at diagnosing and describing cardiovascular diseases in greater detail is made possible by tests such as cardiac computed tomography, cardiac magnetic resonance imaging, and cardiac positron emission tomography. In addition, the aggregation of imaging data with other omics data allows for more personalized treatment and a better description of patient profiles.

Conclusion

The use of advanced imaging tests is essential in cardiovascular precision medicine. Although there are still technical and ethical obstacles, it is essential that there is collaboration between health professionals, as well as investments in technology and education to better disseminate cardiovascular precision medicine and consequently promote improved patient outcomes.

Predicting major adverse cardiovascular events in angina patients using radiomic features of pericoronary adipose tissue based on CCTA

Objective

This study aims to evaluate whether radiomic features of pericoronary adipose tissue (PCAT) derived from coronary computed tomography angiography (CCTA) can better predict major adverse cardiovascular events (MACE) in patients with angina pectoris.

Methods

A single-center retrospective study included 239 patients with angina pectoris who underwent coronary CT examinations. Participants were divided into MACE (n = 46) and non-MACE (n = 193) groups based on the occurrence of MACE during follow-up, and further allocated into a training cohort (n = 167) and a validation cohort (n = 72) at a 7:3 ratio. Automatic segmentation of PCAT surrounding the proximal segments of the left anterior descending artery (LAD), left circumflex coronary artery (LCX), and right coronary artery (RCA) was performed for all patients. Radiomic features of the coronary arteries were extracted, screened, and integrated while quantifying the fat attenuation index (FAI) for the three vessels. Univariate and multivariate logistic regression analyses were utilized to select clinical predictors of adverse cardiovascular events. Subsequently, machine learning techniques were employed to construct models based on FAI, clinical features, and radiomic characteristics. The predictive performance of each model was assessed and compared using receiver operating characteristic (ROC) curves, calibration plots, and decision curve analysis for clinical utility.

Results

The radiomics model demonstrated superior performance in predicting MACE in patients with angina pectoris within both the training and validation cohorts, yielding areas under the curve (AUC) of 0.83 and 0.71, respectively, which significantly outperformed the FAI model (AUC = 0.71, 0.54) and the clinical model (AUC = 0.81, 0.67), with statistically significant differences in AUC (p < 0.05). Calibration curves for all three predictive models exhibited good fit (all p > 0.05). Decision curve analysis indicated that the radiomics model provided higher clinical benefit than the traditional clinical and FAI models.

Conclusion

The CCTA-based PCAT radiomics model is an effective tool for predicting MACE in patients with angina pectoris, assisting clinicians in optimizing risk stratification for individual patients. The CCTA-based radiomics model significantly surpasses traditional FAI and clinical models in predicting major adverse cardiovascular events in patients with angina pectoris.