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Introduction: Vascular inflammation plays a key role in plaque rupture, while the role of inflammation in plaque erosion remains less well defined. Peri-coronary adipose tissue attenuation (PCATA) has emerged as a marker specific for coronary artery inflammation. Direct comparison of the level of vascular inflammation between plaque rupture and plaque erosion has not been reported. Objectives: To compare the level of coronary inflammation between plaque rupture and plaque erosion using PCATA. Methods: Patients with non-ST-segment elevation acute coronary syndromes (NSTE-ACS) who underwent pre-intervention coronary computed tomography angiography and optical coherence tomography (OCT) culprit lesion imaging were enrolled. PCATA was measured in the culprit lesion and in the proximal 40mm segment of the coronary arteries. The relationship between OCT culprit plaque characteristics and PCATA was also examined. Results: Out of 198 patients, plaque rupture was the underlying mechanism in 107 patients (54.0%) and plaque erosion in 91 (46.0%) patients. Plaque rupture had higher PCATA than plaque erosion both at the culprit plaque level (-65.8 ± 7.5 vs. -69.5 ± 11.4 Hounsfield unit [HU], p = 0.010) and at the culprit vessel level (-67.1 ± 7.1 vs. -69.6 ± 8.2 HU, p = 0.024). The mean PCATA of all 3 coronary arteries was also significantly higher in plaque rupture than in plaque erosion indicating a higher level of inflammation (-67.9 ± 5.7 vs. -69.9 ± 6.8 HU, p = 0.030). In the multivariable analysis, plaque rupture was significantly associated with high PCATA at all 3 levels: culprit plaque, culprit vessel, and pan-coronary arteries. Conclusions: PCATA in culprit plaque, culprit vessel, and all 3 coronary arteries was higher in plaque rupture than in plaque erosion. The results indicate pan-coronary inflammation plays a more significant role in plaque rupture than in plaque erosion.

Background: Measuring fractional flow reserve (FFR) with a pressure wire remains underutilized because of the invasiveness of guide wire placement or the need for a hyperemic stimulus. FFR derived from routine coronary angiography (FFR angio ) eliminates both of these requirements and displays FFR values of the entire coronary tree. The FFR angio Accuracy versus Standard FFR (FAST-FFR) study is a prospective, multicenter, international trial with the primary goal of determining the accuracy of FFR angio . Methods: Coronary angiography was performed in a routine fashion in patients with suspected coronary artery disease. FFR was measured in vessels with coronary lesions of varying severity using a coronary pressure wire and hyperemic stimulus. Based on angiograms of the respective arteries acquired in ≥2 different projections, on-site operators blinded to FFR then calculated FFR angio using proprietary software. Coprimary end points were the sensitivity and specificity of the dichotomously scored FFR angio for predicting pressure wire–derived FFR using a cutoff value of 0.80. The study was powered to meet prespecified performance goals for sensitivity and specificity. Results: Ten centers in the United States, Europe, and Israel enrolled a total of 301 subjects and 319 vessels meeting inclusion/exclusion criteria which were included in the final analysis. The mean FFR was 0.81 and 43% of vessels had an FFR≤0.80. The per-vessel sensitivity and specificity were 94% (95% CI, 88% to 97%) and 91% (86% to 95%), respectively, both of which exceeded the prespecified performance goals. The diagnostic accuracy of FFR angio was 92% overall and remained high when only considering FFR values between 0.75 to 0.85 (87%). FFR angio values correlated well with FFR measurements ( r =0.80, P angio was 99%. Conclusions: FFR angio measured from the coronary angiogram alone has a high sensitivity, specificity, and accuracy compared with pressure wire–derived FFR. FFR angio has the promise to substantially increase physiological coronary lesion assessment in the catheterization laboratory, thereby potentially leading to improved patient outcomes. Clinical Trial Registration: URL: https://www.clinicaltrials.gov . Unique Identifier: NCT03226262.

Introduction: Heart failure is strongly linked to renal sodium and water retention as well as intravascular and interstitial fluid shifts. Experimental studies demonstrated a non-osmotic sodium storage, bound to proteoglycans, in the extravascular space. New sodium magnetic resonance imaging ( 23 Na-MRI) enables us to quantify tissue (muscle and skin) sodium content in a reliable and accurate way. Hypothesis: We hypothesised that the increase of tissue sodium content is dependent on the severity of chronic heart failure (CHF). Methods: We investigated patients with stable CHF before initiating treatment with an SGLT2-inhibitor within a prospective, placebo-controlled study. We here report the baseline data of 64 patients with CHF, defined as patients with reduced (HFrEF) or mid-range ejection fraction (HFmEF). In each patient, tissue sodium content of the lower leg was assessed non-invasively by a clinical 3.0T 23 Na-MRI. The median NT-proBNP plasma level at baseline was 493.3pg/ml (IQR: 225.8-1122.0pg/ml) and was used as cut off value of CHF severity. Results: Our patients (men: n=54) were 66.9±8.9 years old and had NYHA class II-III; mean muscle sodium content was 19.1±3.8mmol/l and mean skin sodium content was 22.5±5.9mmol/l. Our reference for young healthy subjects are 18.7±2.0 mmol/l for muscle sodium content and 19.6±3.1 mmol/l for skin sodium content. Patients with CHF and NT-proBNP levels above the median showed higher muscle (20.2±3.5 vs 17.9±3.7mmol/l, p=0.008) and skin sodium content (24.1±6.8 vs 20.8±4.4mmol/l, p=0.005) than patients with CHF and NT-proBNP levels below the median. No difference in plasma sodium levels between the two groups (138.0±3.7 vs 138.8±2.1mmol/l, p=0.527) was observed, but patients with NT-proBNP levels above the median had lower urinary sodium excretion over 24 hours (167.0±78.8 vs 172.3±63.4mmol/l, p=0.009). Age was different in the two groups (69.88±8.2 vs 63.8±8.7, p Conclusion: Concluding, tissue sodium content in patients with stable CHF as assessed by 23 Na-MRI increases with the severity of CHF. A decrease of tissue sodium content might be a future therapeutic goal.

Introduction: Chronic heart failure (CHF) and impaired renal function are two co-existing medical conditions and known to be associated with adverse outcome. The cardiorenal interaction has not yet been analyzed thoroughly. The aim of this study was to assess renal and intraglomerular hemodynamics by constant infusion input clearance technique in subjects with CHF compared to healthy controls. Methods: This was a cross-sectional observational study including 85 subjects. The group of subjects with CHF consisted of 27 individuals with HFpEF and 27 individuals with HFrEF, who were compared to 31 controls. All subjects underwent renal clearance examination to determine measured -not estimated- glomerular filtration rate (GFR), renal blood and plasma flow (RBF, RPF) and to calculate renal hemodynamic parameters such as filtration fraction (FF), renal vascular resistance (RVR), intraglomerular pressure (P glom ) and resistances of the afferent (R A ) and efferent arterioles (R E ). Results: GFR was lower in subjects with CHF (88.6±13.1ml/min/1.73m 2 ) compared to controls (108.6±17. ml/min/1.73m 2 ) after adjustment for age and BP (p adj =0.037). There were no significant differences regarding RPF, RBF, FF, RVR, P glom , R A as well as R E after adjustment for age and BP. Similarly, there were no significant differences regarding renal hemodynamic parameters between HFpEF and HFrEF subjects. Bivariate correlation analysis in the group of subjects with CHF revealed an inverse association between NT-proBNP and RPF (R=-0.421, p=0.002), RBF (R=-0.414, p=0.002) and a positive association with FF (R=0.324, p=0.019), RVR (R=0.346, p=0.012) and R E (R=0.318, p=0.022). Conclusions: The findings of this study indicate that in CHF renal function is slightly reduced even though renal perfusion is preserved. With progressive severity of CHF as indicated by increasing NT-proBNP, renal vascular resistance in particular at the postglomerular side increases. Our data are in accordance with neuroendocrine activation in CHF since vasoconstriction at the postglomerular site points towards angiotensin II as mediator. The association between NT-proBNP and renal hemodynamics documents a close cardiorenal interaction in CHF.

This summer brought cardiologists from all over the world to Barcelona, when the European Society of Cardiology (ESC) hosted ESC Congress 2017 in August 2017 (Figure 1). With 31 175 attendees from a record-breaking 153 countries and participants being able to choose from 780 sessions running in 28 parallel rooms, the 4.5-day event was 1 of the largest cardiovascular congresses ever. ESC’s call for abstracts attracted >10 804 submissions, of which 4514 (42%) were selected for oral or poster presentation. Interestingly, the country from which the most abstracts were submitted—and accepted—was not in Europe. It was Japan, which has held first place in abstract submissions for the last 7 years. The United States, Korea, and China were also among the top 10 abstract submitting countries—a fact that highlights the increasingly global character of this conference. Figure 1. The ESC Congress 2017 was hosted in Barcelona, Spain in August 2017 . For the educational component of ESC 2017 in Barcelona, >1574 faculty members from 74 countries had active roles. With ESC’s efforts to increase the role of women in the program, a record 24% of invited presenters were female, up from 20% in previous years. As is typical, 3 areas of the ESC Congress attracted particular interest. There was the regularly featured Congress Spotlight, which in 2017—in line with the 40th anniversary of the first percutaneous coronary intervention performed …

Can stents replace coronary artery bypass surgery? Certainly not. There are some patients with coronary artery lesions that are not amenable to stent placement, there are some patients where stent placement is prognostically inferior to bypass surgery, and there are some situations in which bypass surgery must be used when the attempt to treat a lesion by stent placement failed or resulted in a complication. Does this mean that coronary stents are useless? Certainly not—coronary stents have saved lives and relieved symptoms and continue to do so. They are an alternative to coronary artery bypass surgery in many situations, and they provide a less invasive and economically favorable alternative to open heart surgery. Could we do completely without stenting? Probably we could,1 but the most reasonable approach is to use them when it makes sense. Can coronary computed tomography angiography (coronary CTA) replace invasive angiography? Based on the short introduction, it is probably rather evident what I consider the obvious answer to be: No, coronary CTA cannot entirely replace invasive coronary angiography, but it does not have to to be useful. Could we do completely without coronary CT angiography? Probably we could, but why keep the noninvasive alternative to cardiac catheterization from our patients if there are situations in which a well-performed coronary CTA clearly obviates the need for an invasive angiogram? Response by Stefanini and Windecker on p 417 Let’s take the situation of a 57-year-old female patient I’ll refer to as Betty (even though her true name is different). She reported some rather typical-sounding chest pain on exercise and occasionally at rest. Bicycle stress ECG testing was performed and led to ST–segment depression in the inferior leads (see Figure 1), reproducible on 2 occasions. Her treating cardiologist discussed invasive coronary angiography as the next diagnostic step, with …

Background: Non-invasive detection of vascular inflammation remains an unmet goal. We hypothesized that phenotypic changes in perivascular adipose tissue (PVAT) induced by vascular inflammation can be quantified using a new computed tomography angiography (CTA) methodology. Methods: In Arm 1, human PVAT adipocytes were cultured +/- inflammatory cytokines (n=7) or co-cultured with vascular tissue (+/-Angiotensin-II, n=6) to assess the effects of vascular inflammation on PVAT differentiation. In Arm 2, AT explants (epicardial, subcutaneous and thoracic AT) from 453 cardiac surgery patients were used in histology and gene expression studies to relate the ex vivo images with in vivo CT scan information (n=105) on the biology of the explants. In Arm 3, in 267 patients undergoing diagnostic CTA, PVAT attenuation (Fat Attenuation Index (FAI) defined as the average CT attenuation of AT), was analysed around the proximal right coronary artery. In Arm 4, PVAT FAI around unstable (culprit) and stable coronary plaques was calculated in 22 CAD patients undergoing CTA. Results: In Arm 1, Angiotensin-II (A) and proinflammatory cytokines (B) prevented lipid accumulation and adipocyte differentiation in cultured PVAT. In Arm 2, adipocyte size by histology was inversely correlated with FAI in vivo (C). Both FAI of AT explants (not shown) and FAI in-vivo (n=105) were negatively associated with epicardial AT differentiation as assessed by FABP4 expression (D). In Arm 3, PVAT FAI change over distance from RCA wall was significantly different in CAD compared to no CAD patients (E). In Arm 4, PVAT FAI was significantly increased around unstable plaques (F). Conclusions: Human vessels exert paracrine effects on surrounding PVAT, affecting local intracellular lipid accumulation in preadipocytes, which can then be monitored using a CT imaging approach. This novel methodology can be implemented in clinical practice to detect unstable plaques in the human coronary vasculature.

Background— Multidetector computed tomographic angiography (MDCT) has been shown to allow detection of coronary artery bypass graft (CABG) occlusions and stenoses. However, the assessment of native coronary arteries in addition to CABG has thus far not been sufficiently validated. Methods and Results— Fifty patients with a total of 138 CABG (34 mammary grafts, 3 radial grafts, 101 venous grafts) were investigated by MDCT (0.6-mm collimation, 32 detector rows, 2 focal points, 330-ms rotation) 9 to 252 months (mean, 106 months) after surgery. CABG and all native coronary arteries with a diameter of >1.5 mm were evaluated for the presence of significant stenoses (≥50% diameter reduction). Results were compared with quantitative coronary angiography. By MDCT, all CABG were evaluable and were correctly classified as occluded (n=38) or patent (n=100). Sensitivity for stenosis detection in patent grafts was 100% (16/16) with a specificity of 94% (79/84). For the per-segment evaluation of native coronary arteries and distal runoff vessels, sensitivity in evaluable segments (91%) was 86% (87/101) with a specificity of 76% (354/465). If evaluation was restricted to nongrafted arteries and distal runoff vessels, sensitivity was 86% (38/44) with a specificity of 90% (302/334). On a per-patient basis, classifying patients with at least 1 detected stenosis in a CABG, a distal runoff vessel, or a nongrafted artery or with at least 1 unevaluable segment as “positive,” MDCT yielded a sensitivity of 97% (35/36) and specificity of 86% (12/14). Conclusions— We found that 64-slice MDCT permits the evaluation of bypass grafts and the assessment of the native coronary arteries for the presence of stenosis.

Background— Noninvasive assessment of coronary atherosclerotic plaque and significant stenosis by coronary multidetector computed tomography (MDCT) may improve early and accurate triage of patients presenting with acute chest pain to the emergency department. Methods and Results— We conducted a blinded, prospective study in patients presenting with acute chest pain to the emergency department between May and July 2005 who were admitted to the hospital to rule out acute coronary syndrome (ACS) with no ischemic ECG changes and negative initial biomarkers. Contrast-enhanced 64-slice MDCT coronary angiography was performed immediately before admission, and data sets were evaluated for the presence of coronary atherosclerotic plaque and significant coronary artery stenosis. All providers were blinded to MDCT results. An expert panel, blinded to the MDCT data, determined the presence or absence of ACS on the basis of all data accrued during the index hospitalization and 5-month follow-up. Among 103 consecutive patients (40% female; mean age, 54±12 years), 14 patients had ACS. Both the absence of significant coronary artery stenosis (73 of 103 patients) and nonsignificant coronary atherosclerotic plaque (41 of 103 patients) accurately predicted the absence of ACS (negative predictive values, 100%). Multivariate logistic regression analyses demonstrated that adding the extent of plaque significantly improved the initial models containing only traditional risk factors or clinical estimates of the probability of ACS (c statistic, 0.73 to 0.89 and 0.61 to 0.86, respectively). Conclusions— Noninvasive assessment of coronary artery disease by MDCT has good performance characteristics for ruling out ACS in subjects presenting with possible myocardial ischemia to the emergency department and may be useful for improving early triage.

This scientific statement reviews the scientific data for cardiac computed tomography (CT) related to imaging of coronary artery disease (CAD) and atherosclerosis. Cardiac CT is a CT imaging technique that accounts for cardiac motion, typically through the use of ECG gating. The utility and limitations of generations of cardiac CT systems are reviewed in this statement with emphasis on CT measurement of CAD and coronary artery calcified plaque (CACP) and noncalcified plaque. Successive generations of CT technology have been applied to cardiac imaging beginning in the early 1980s with conventional CT, electron beam CT (EBCT) in 1987, and multidetector CT (MDCT) in 1999. Compared with other imaging modalities, cardiac CT has undergone an accelerated …

Introduction: Data describing the prevalence, characteristics, and management of chronic total occlusions (CTO) in patients undergoing coronary computed tomography angiography (CCTA) have not been reported. Objectives: The purpose of this study was to determine the prevalence, characteristics, and treatment strategies of CTO identified by CCTA. Methods: We identified 23,745 patients who underwent CCTA for suspected coronary artery disease (CAD) from the CONFIRM (COronary CT Angiography EvaluatioN For Clinical Outcomes: An InteRnational Multicenter) registry. Baseline clinical data were collected, and allocation to early coronary revascularization performed within 90 days of CCTA was determined. Multivariable logistic regression reporting odds ratios (OR) with 95% confidence intervals (95%CI) was performed. Results: Patients with CTO were older (64.7 ± 10.8 vs 57.2 ± 12.6 years, p Conclusions: CTOs are not uncommon in a contemporary CCTA population and are associated with age, gender, angina status and CAD risk factors. Most individuals with CTO undergoing CCTA are managed medically with higher rates of surgical revascularization in patients with versus without CTO.

Background Recent studies demonstrated an influence of atherosclerotic risk factors on the progression of aortic valve stenosis. The extent of aortic valve calcification (AVC) was also found to be a strong predictor of stenosis progression. We investigated the influence of the LDL cholesterol level (LDL), other standard cardiovascular risk factors, and the extent of coronary calcification (CC) on the progression of AVC quantified by electron beam tomography (EBT). Methods and Results In 104 patients (64.7±8 years, 89 male) with an EBT scan positive for AVC, CC and AVC were quantified using a volumetric score. EBT was repeated at a mean interval of 15 months (10 to 36 months), and the progression of AVC and CC was determined. Patients were divided into 2 groups according to LDL: group 1, LDL≤3.36 mmol/L (130 mg/dL), 57 patients; group 2, LDL>3.36 mmol/L (130 mg/dL), 47 patients. Mean values for CC were 546±932 mm 3 in scan 1 and 665±1085 mm 3 in scan 2 for AVC 324±796 mm 3 and 404±1076 mm 3 , respectively. The mean progression of CC was 27±37% (group 1, 16±22%; group 2, 39±46%, P ≤0.001) and of AVC was 25±38% (group 1, 9±22%; group 2, 43±44%, P ≤0.001). Conclusions Quantification of AVC by EBT permits new insights into the progression of aortic valve sclerosis. We observed a strong influence of LDL cholesterol level on the progression of AVC and CC, suggesting that lipid-lowering therapy may decrease the progression of aortic valve calcification.

Background —We investigated the applicability and image quality of contrast-enhanced coronary artery visualization by multislice spiral CT using retrospective ECG gating. Methods and Results —Twenty-five patients in sinus rhythm (significant coronary artery stenoses ruled out by invasive angiography) were studied with a multislice spiral CT (Siemens SOMATOM Volume Zoom). In inspiration (mean breathhold, 37 seconds), a volume data set of the heart was acquired (intravenous contrast agent; 4×1-mm slice thickness; 500-ms rotation; table feed, 1.5 mm/360°). Simultaneous recording of the ECG permitted retrospective reconstruction of contiguous cross sections in intervals of 1 mm at any desired interval of the cardiac cycle. The mean duration of the image reconstruction window was 185 ms. Next to 3-dimensional reconstructions of the heart and coronary arteries, multiplanar reconstructions were rendered to determine the visualized length of the coronary arteries, the contrast-to-noise ratio, and the correlation of coronary artery diameters to quantitative coronary angiography. Conclusions —The coronary arteries could be visualized over long segments (left main, 9±4 mm; left anterior descending, 112±34 mm; left circumflex, 80±29 mm; right coronary artery, 116±33 mm). On average, 78±16% of these distances were visualized free of motion artifacts. The mean contrast-to-noise ratio was 9.3±3.3. Coronary artery diameters in multislice spiral CT showed close correlation to quantitative coronary angiography (CT, 3.3±1.0 mm; angiography, 3.2±0.9 mm; mean difference, 0.38 mm; r =0.86). Contrast-enhanced multislice spiral CT permits visualization of the coronary artery lumen. Further studies are necessary to determine whether image quality is sufficient to reliably detect coronary artery stenoses.

Background— We analyzed the accuracy of multi-detector row spiral computed tomography (MDCT) using a 16-slice CT scanner with improved spatial and temporal resolution, as well as routine premedication with β-blockers for detection of coronary stenoses. Methods and Results— Seventy-seven patients with suspected coronary disease were studied by MDCT (12×0.75-mm cross-sections, 420 ms rotation, 100 mL contrast agent IV at 5 mL/s). Patients with a heart rate above 60/min received 50 mg atenolol before the scan. In axial MDCT images and multiplanar reconstructions, all coronary arteries and side branches with a diameter of 1.5 mm or more were assessed for the presence of stenoses exceeding 50% diameter reduction. In comparison to invasive coronary angiography, MDCT correctly classified 35 of 41 patients (85%) as having at least 1 coronary stenosis and correctly detected 57 of 78 coronary lesions (73%). After excluding 38 of 308 coronary arteries (left main, left anterior descending, left circumflex, and right coronary artery in 77 patients) classified as unevaluable by MDCT (12%), 57 of 62 lesions were detected, and absence of stenosis was correctly identified in 194 of 208 arteries (sensitivity: 92%; specificity: 93%; accuracy: 93%; positive and negative predictive values: 79% and 97%). Conclusions— MDCT coronary angiography with improved spatial resolution and premedication with oral β-blockade permits detection of coronary artery stenoses with high accuracy and a low rate of unevaluable arteries.

Background— The predictive value of coronary computed tomographic angiography (cCTA) in subjects without chest pain syndrome (CPS) has not been established. We investigated the prognostic value of coronary artery disease detection by cCTA and determined the incremental risk stratification benefit of cCTA findings compared with clinical risk factor scoring and coronary artery calcium scoring (CACS) for individuals without CPS. Methods and Results— An open-label, 12-center, 6-country observational registry of 27 125 consecutive patients undergoing cCTA and CACS was queried, and 7590 individuals without CPS or history of coronary artery disease met the inclusion criteria. All-cause mortality and the composite of all-cause mortality and nonfatal myocardial infarction were measured. During a median follow-up of 24 months (interquartile range, 18–35 months), all-cause mortality occurred in 136 individuals. After risk adjustment, compared with individuals without evidence of coronary artery disease by cCTA, individuals with obstructive 2- and 3-vessel disease or left main coronary artery disease experienced higher rates of death and composite outcome ( P P Conclusions— Although the prognosis for individuals without CPS is stratified by cCTA, the additional risk-predictive advantage by cCTA is not clinically meaningful compared with a risk model based on CACS. Therefore, at present, the application of cCTA for risk assessment of individuals without CPS should not be justified.

Since the early 1960s, selective x-ray coronary angiography has provided the only means of visualizing the coronary arterial system in vivo. However, it has several disadvantages. First, the incidence, albeit relatively low, of so-called major adverse events (death, myocardial infarction, or stroke) during or within 24 hours of selective coronary angiography is reported to be 0.2% to 0.3%, and the incidence of so-called minor complications (most of which are related to problems with the peripheral vessels through which catheters are inserted) is roughly 1% to 2%.1–3 Second, x-ray coronary angiography is accompanied by a modest amount of discomfort, because the placement of catheters is invasive. Third, it is expensive: the required equipment is costly, and the performance of the procedure necessitates considerable time and skill of highly trained physicians and support personnel. Last, the information obtained via catheter-based coronary angiography pertains to the coronary arterial lumen alone. As a result, alternative methods of visualizing the coronary arterial system that would allow one to avoid these disadvantages are desirable. Over the past 15 years, substantial advances have been made in noninvasive cardiac imaging in general and in visualization of the coronary arteries in particular. Magnetic resonance angiography (MRA) of the coronary arteries was advanced in the early 1990s with the development of high-speed gradient techniques and dedicated cardiac coils. The primary advantage of this technique is the patient’s lack of exposure to ionizing radiation or iodinated contrast media. Coronary MRA may also be combined with other magnetic resonance (MR) imaging techniques for assessment of cardiac function, structure, blood flow, and viability.4 Electron-beam computed tomography (CT) with iodinated contrast injection was originally used to perform coronary angiograms, but this has been supplanted by multidetector CT (MDCT) scanners that have 16 to 256 rows of detectors. MDCT can provide visually compelling …

Background In addition to high spatial (0.4 mm) and temporal resolution (83 ms), Dual Source CT (DSCT) allows simultaneous imaging with two different x-ray energies. This may be beneficial for tissue characterization. Objectives. To determine the accuracy of ex vivo atherosclerotic plaque characterization with DSCT and to assess the CT attenuation of various plaque components depending on X-ray energy. Materials and Methods. 18 atherosclerotic vessels of coronary, carotid and iliac arteries obatined from autopsy were analyzed by DSCT. Each lumen of the vessels was filled with contrast media (30X Imeron 350). The collimation was 2X64X0.6 mm, rotation time was 330 msec., temporal resolution was 83 msec. Data sets were obtained using a tube voltage of 80, 100, 120, and 140 kV. The x.-ray attenuation of lipid-rich plaque, fibrous plaque, calcified plaque and contrast-enhanced lumen were determined for all x-ray energies by comparison to histology at 25 sites. In addition, cross-sectional images were reconstructed with 0.75 mm slice thickness and 0.4 mm increment. 26 slices at 10 mm interval were analyzed by comprehensive color-coding according to CT number. Results. There were significant differences among CT attenuations of lipid-rich, fibrous and calcified plaque using 80, 100, 120, and 140 kV (Table , p Conclusions. The relationships between lumen enhancement and each plaque component were different as changing the x-ray energy level. Using of varying x-ray energy, DSCT may able to detect atherosclerotic plaque and characterization of plaque components. The Attenuation on Different Energy

Objective : To determine CT angiographic patterns of coronary plaque and stenosis and diagnostic test characteristics of these findings to predict ACS in patients presenting with acute chest pain to the emergency department (ED). Methods : We conducted a blinded, prospective, observational cohort study in patients presenting with acute chest pain to the ED between May 2005 and July 2006, who were admitted to the hospital to rule out acute coronary syndrome (ACS) with no ischemic ECG changes and negative initial biomarkers. Contrast-enhanced 64-slice cardiac CT was performed immediately before admission and caregivers were blinded to the cardiac CT results. An expert panel determined the presence or absence of ACS (unstable angina pectoris [UAP], Non-ST-Elevation Myocardial Infarction [MI] according to AHA/ACC criteria). Two independent observers evaluated cardiac CT data sets for the presence of (1) coronary atherosclerotic plaque, and (2) significant coronary artery stenosis (>50%). Results: Of 221 consecutive patients (44% female, mean age 55±12 years), 31 patients had ACS (10 NSTEMI, 21 UAP). The presence of any coronary atherosclerotic plaque could be excluded in 82 patients (37%). None of these subjects was determined to have ACS (Sensitivity and NPV: 100%, (95% CI: 0.91–1.00 and 0.96–1.00; respectively). The presence of a significant coronary artery stenosis could be excluded in 152 subjects (69%). Overall, three of these patients had ACS during the index hospitalization (NPV, 98 %; 95% CI: 0.94–1.00). In 69 patients (31%), a significant stenosis was either detected or could not be completely excluded. Among them were 28/31 patients with ACS (specificity: 78%, 95% CI: 0.72– 0.84; PPV: 41% 95% CI: 0.29 – 0.53). Conclusions : These data extend initial observations that nearly 40% and 70% of patients with acute chest pain demonstrate no detectable CAD or no significant coronary artery stenosis on cardiac MDCT, respectively. Randomized diagnostic trials are warranted to determine how this information will be used by ED physicians and whether it will decrease the number of unnecessary admissions.

We thank Dr Hamon and colleagues1 for their interest in our work. We agree that our data demonstrate that both the absence of coronary artery plaque or stenosis on noninvasive coronary multidetector computed tomography (MDCT) angiography has high negative predictive value for the subsequent diagnosis of acute coronary syndrome. However, as …

Background— Recent clinical trials have suggested that intensive versus standard lipid-lowering therapy provides for additional benefit. Electron-beam computed tomography provides the opportunity to quantify the progression of coronary artery calcification (CAC) in serial measurements. Methods and Results— In a multicenter, randomized, double-blind trial, 471 patients (age 61±8 years) who had no history of coronary artery disease and no evidence of high-grade coronary stenoses (>50% diameter reduction) were randomized if they had ≥2 cardiovascular risk factors and moderate calcified coronary atherosclerosis as evidenced by a CAC score ≥30. Patients were assigned to receive 80 mg or 10 mg of atorvastatin per day over 12 months. Progression of CAC volume scores could be analyzed in 366 patients. After pretreatment with 10 mg of atorvastatin for 4 weeks, 12 months of study medication reduced LDL cholesterol from 106±22 to 87±33 mg/dL in the group randomized to receive 80 mg of atorvastatin ( P P =NS). The mean progression of CAC volume scores, corrected for the baseline CAC volume score, was 27% (95% CI 20.8% to 33.1%) in the 80-mg atorvastatin group and 25% (95% CI 19.1% to 30.8%) in the 10-mg atorvastatin group ( P =0.65). CAC progression showed no relationship with on-treatment LDL cholesterol levels. Conclusions— We did not observe a relationship between on-treatment LDL cholesterol levels and the progression of calcified coronary atherosclerosis. Over a period of 12 months, intensive atorvastatin therapy was unable to attenuate CAC progression compared with standard atorvastatin therapy. The possibility remains that the time window was too short to demonstrate an effect.

Background— Characteristics of individual calcified plaques, especially calcium concentration (CC), may provide incremental value to global calcium scores in the assessment of plaque burden and risk of coronary events and evaluation of therapeutic intervention. In this study, therefore, we assessed the characteristics of individual calcified plaques and their relationship to other parameters derived from CT analysis of coronary calcium in a community-based cross-sectional cohort. Methods and Results— Coronary artery calcium (CAC) was analyzed in 612 participants of the Framingham Heart Study (third-generation and offspring cohorts) using prospectively ECG-triggered multidetector CT. We determined the CC, Agatston score, calcified volume, and mineral mass of individual calcified plaques in each subject. Heterogeneity of CC was defined as the standard deviation of CC of all individual calcified plaques in a subject. CAC was detected in 274 of 605 subjects. After excluding 57 subjects (21%) because of motion artifacts, we identified a total of 956 calcified coronary plaques in 217 subjects (74 women, 143 men; mean age, 57.1±10.8 years) with detectable CAC and no image artifacts. CC of individual calcified plaques was independent of subject age ( P =0.76) and sex (197.8±74.8 versus 183.6±52.8 mg/cm 3 for men versus women; P =0.21). Among a subgroup of 125 subjects with multiple (≥3) individual calcified plaques, CC was heterogeneous within individual subjects (mean SD of CC, 43.6±23.1 mg/cm 3 ). The degree of heterogeneity of CC in these subjects was independent of age ( P =0.60), sex ( P =0.99), and number of plaques ( P =0.06). Conclusions— The CC of individual calcified plaques is independent of age and sex but heterogeneous within a subject, which may reflect that the pathological process of calcified plaque formation and progression is the same in men and women regardless of age. CC may have incremental value to global calcium scores in the assessment of plaque burden and risk of coronary events and the evaluation of therapeutic intervention. Further studies are warranted to confirm that individual plaque analysis is preferable to global CAC scores to evaluate progression of atherosclerosis and to assess whether individual plaque analysis may be complementary to global CAC measures to assess coronary event risk.

A 69-year-old man, who had been asymptomatic for 12 years after aorto-coronary venous bypass surgery, was admitted for the evaluation of a large mass adjacent to the left heart border detected by routine chest radiography (Figure 1). Further diagnostic evaluation included a contrast-enhanced multi-detector row spiral computed tomography scan of the chest that revealed a large left anterior mediastinal mass abutting the left ventricle, right ventricle, and pulmonary artery (Figure 2). In addition, a second mass adjacent to the ascending aorta and the right atrium was detected. Both structures were partly filled with contrast agent, confirming their vascular nature. On the basis of these findings, giant aneurysms of …

Background— We investigated the ability of multidetector spiral computed tomography (MDCT) to detect atherosclerotic plaque in nonstenotic coronary arteries. Methods and Results— In 22 patients without significant coronary stenoses, contrast-enhanced MDCT (0.75-mm collimation, 420-ms rotation) and intravascular ultrasound (IVUS) of one coronary artery were performed. A total of 83 coronary segments were imaged by IVUS (left main, 19; left anterior descending, 51; left circumflex, 4; right coronary, 9). MDCT data sets were evaluated for the presence and volume of plaque in the coronary artery segments. Results were compared with IVUS in a blinded fashion. For the detection of segments with any plaque, MDCT had a sensitivity of 82% (41 of 50) and specificity of 88% (29 of 33). For calcified plaque, sensitivity was 94% (33 of 36) and specificity 94% (45 of 47). Coronary segments containing noncalcified plaque were detected with a sensitivity of 78% (35 of 45) and specificity of 87% (33 of 38), but presence of exclusively noncalcified plaque was detected with only 53% sensitivity (8 of 15). If analysis was limited to the 41 proximal segments (segments 1, 5, 6, and 11 according to American Heart Association classification), sensitivity and specificity were 92% and 88% for any plaque, 95% and 91% for calcified plaque, and 91% and 89% for noncalcified plaque. MDCT substantially underestimated plaque volume per segment as compared with IVUS (24±35 mm 3 versus 43±60 mm 3 , P Conclusions— The results indicate the potential of MDCT to detect coronary atherosclerotic plaque in patients without significant coronary stenoses. However, further improvements in image quality will be necessary to achieve reliable assessment, especially of noncalcified plaque throughout the coronary tree.

Background— Coronary calcification measured by fast computed tomography techniques is a surrogate marker of coronary atherosclerotic plaque burden. In a cohort study, we prospectively investigated whether lipid-lowering therapy with a cholesterol synthesis enzyme inhibitor reduces the progression of coronary calcification. Methods and Results— In 66 patients with coronary calcifications in electron beam tomography (EBT), LDL cholesterol >130 mg/dL, and no lipid-lowering treatment, the EBT scan was repeated after a mean interval of 14 months and treatment with cerivastatin was initiated (0.3 mg/d). After 12 months of treatment, a third EBT scan was performed. Coronary calcifications were quantified using a volumetric score. Cerivastatin therapy lowered the mean LDL cholesterol level from 164±30 to 107±21 mg/dL. The median calcified volume was 155 mm 3 (range, 15 to 1849) at baseline, 201 mm 3 (19 to 2486) after 14 months without treatment, and 203 mm 3 (15 to 2569) after 12 months of cerivastatin treatment. The median annualized absolute increase in coronary calcium was 25 mm 3 during the untreated versus 11 mm 3 during the treatment period ( P =0.01). The median annual relative increase in coronary calcium was 25% during the untreated versus 8.8% during the treatment period ( P P =0.0001). Conclusions— Treatment with the cholesterol synthesis enzyme inhibitor cerivastatin significantly reduces coronary calcium progression in patients with LDL cholesterol >130 mg/dL.

An aberrant origin of the left main coronary artery (LM) or left anterior descending coronary artery (LAD) from the right sinus of Valsalva is a rare anomaly that has been associated with myocardial ischemia and sudden cardiac death. Depending on the anatomic relationship of the anomalous vessel to the aorta and the pulmonary trunk, the anomaly can be classified into 4 common courses: posterior, interarterial, anterior, and septal course. Contrast-enhanced electron beam tomography (EBT) has been shown to permit classification of anomalous coronary arteries. We present 4 cases that illustrate the common variations of this anomaly. In all cases, EBT was performed using a C-150 XP EBT scanner (Imatron Inc). During inspiratory breathhold, 40 to 50 axial cross-sections of the heart were acquired triggered to the ECG at 40% of the R-R interval (100 ms acquisition time, slice thickness 3 mm, table feed 2 mm, intravenous injection of 160 mL contrast agent …

Background —Multislice spiral computed tomography (MSCT) with retrospectively ECG-gated image reconstruction permits coronary artery visualization. We investigated the method’s ability to identify high-grade coronary artery stenoses and occlusions. Methods and Results —A total of 64 consecutive patients were studied by MSCT (4×1 mm cross-sections, 500-ms rotation, table feed 1.5 mm/rotation, intravenous contrast agent, retrospectively ECG-gated image reconstruction). All coronary arteries and side branches with a luminal diameter ≥2.0 mm were assessed concerning evaluability and the presence of high-grade stenoses (>70% diameter stenosis) or occlusions. Results were compared with quantitative coronary angiography. Of 256 coronary arteries (left main, left anterior descending, left circumflex and right coronary artery, including their respective side branches), 174 could be evaluated (68%). In 19 patients (30%), all arteries were evaluable. Artifacts caused by coronary motion were the most frequent reason for unevaluable arteries. Overall, 32 of 58 high-grade stenoses and occlusions were detected by MSCT (58%). In evaluable arteries, 32 of 35 lesions were detected, and the absence of stenosis was correctly identified in 117 of 139 arteries (sensitivity, 91%; specificity, 84%). If analysis was extended to all stenoses with >50% diameter reduction, sensitivity was 85% (40 of 47) and specificity was 76% (96 of 127). Conclusions —MSCT with retrospective ECG gating permits the detection of coronary artery stenoses with high accuracy if image quality is sufficient, but its clinical use may presently be limited due to degraded image quality in a substantial number of cases, mainly due to rapid coronary motion.

A 58-year-old woman presented with a 2-week history of acute dyspnea in the setting of subtherapeutic warfarin anticoagulation (international normalized ratio, 1.7 on admission) with a history of previous St. Jude bileaflet aortic valve replacement (AVR) 5 years previously. Transthoracic echocardiography revealed severe elevation of the prosthetic aortic transvalvular gradient (peak velocity, 5 m/s; peak gradient, 125 mm Hg) with severe eccentric aortic regurgitation. The morphology of the prosthetic aortic valve was not clearly visualized secondary to an acoustic shadow from the metallic prosthesis. The patient was referred to cardiac computed tomography (CT) for further evaluation of prosthetic dysfunction and to exclude coronary artery disease in case surgical intervention was required.

Background Contrast-enhanced electron beam computed tomography (EBCT) has been shown to permit noninvasive visualization of the coronary arteries. We determined the value of EBCT to noninvasively detect high-grade restenosis after percutaneous transluminal coronary angioplasty (PTCA). Methods and Results Fifty patients (37 to 68 years of age), were investigated by EBCT at a mean interval of 9 months after PTCA of coronary artery stenoses. Forty axial cross-sections of the heart (3-mm slice thickness, 1-mm overlap) were acquired triggered to the ECG after intravenous injection of contrast agent. Three-dimensional reconstructions of the coronary arteries were rendered with a lower threshold of 80 HU to selectively visualize the contrast-enhanced vessel lumen. EBCT results were compared with conventional quantitative coronary angiography (QCA) performed within 1 week. In 6 patients, the PTCA segment could not be evaluated because of impaired image quality. Sixteen of the remaining 44 patients had high-grade restenoses in QCA (>70% diameter reduction), which was correctly detected by EBCT in 15 cases (94% sensitivity). There were 5 false-positive EBCT results of high-grade restenosis (82% specificity). Conclusions EBCT with intravenous injection of contrast agent permits the noninvasive diagnosis of restenosis after PTCA, with high sensitivity and sufficient specificity.

Background— Guidelines for the management of patients with suspected coronary artery disease (CAD) rely on the age, sex, and angina typicality–based pretest probabilities of angiographically significant CAD derived from invasive coronary angiography (guideline probabilities). Reliability of guideline probabilities has not been investigated in patients referred to noninvasive CAD testing. Methods and Results— We identified 14048 consecutive patients with suspected CAD who underwent coronary computed tomographic angiography. Angina typicality was recorded with the use of accepted criteria. Pretest likelihoods of CAD with ≥50 diameter stenosis (CAD50) and ≥70 diameter stenosis (CAD70) were calculated from guideline probabilities. Computed tomographic angiography images were evaluated by ≥1 expert reader to determine the presence of CAD50 and CAD70. Typical angina was associated with the highest prevalence of CAD50 (40 in men, 19 in women) and CAD70 (27 men, 11 women) compared with other symptom categories ( P P Conclusion— In this multinational study of patients referred for coronary computed tomographic angiography, determination of pretest likelihood of angiographically significant CAD by the invasive angiography-based guideline probabilities greatly overestimates the actual prevalence of disease.